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anesthesia for genitourinary surgery > Chapter 31 > Flashcards

Chapter 31 Flashcards

1
Q

which position is most commonly used for patients undergoing urological and gyncological procedureas

A

lithotomy

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2
Q

pad points in lithotomy or you can get

A

pressure sore, never injury or compartment syndromes

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3
Q

can lose dorsiflexion of the foot if what nerve is affected if lateral knee rests against the strap support

A

peroneal never

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4
Q

medially placed strap supports can cause spaphenous nerve injury which is shown as

A

numbness along the medial calf

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5
Q

lithotomy position can have nerve injuries to sciatic and femoral nerves in the

A

lumbosacral plexus

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6
Q

hyperextension of the axilla can cause

A

brachial plexus damage

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7
Q

can get compartment syndrome of lower extremeties

A

pressure buildup

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8
Q

in lithotomy the FRC in combindation with steep trendelenburg

A

decreases, so you can get atelectasis and hypoxia

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9
Q

lithotomy bad for CHF makes it worse but can be better for

A

hypovolemia because blood is drained to central compartment

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10
Q

bp and CO may inc in lithotomy but get ____ when taken out of lithotomy

A

hypotension-take bp after legs are down, general anesthesia vasodialates

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11
Q

short duration and outpatient setting of cystos you use

A

gen anesthesia with lma

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12
Q

you can use spinal or epidural for cysto, but prefer spinal becuase after sensory blockade which is

A

5 min versus 20 min

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13
Q

sensory level __ provides exceelnt ansethesia for all cystoscopic procedures

A

T10

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14
Q

BPH is

A

benign prostatic hyperplasia leading to bladder outlet obsturction

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15
Q

TURP

A

transurethral resection of prostate

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16
Q

TURP can be done under regional or general

-surgical complications

A

most common surgical complications are clot retention , failure to void , chronic hematuria,, TURP syndrome, bladder perforation sepsis, DIC-disseminated intravascular coagulation

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17
Q

prostatic bleeding is hard to control

A

get type and screen and corss on anemica patients

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18
Q

TURP syndrome-opens extensive netowrk of venous sinuses in prostrate allowing absorption of

A

irrigating fluid

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19
Q

signs and symptoms of turp syndrome (less than 1%)

A

headache, restlessness, confusion cyanosis, dyspnea, arrhythmias, hypotension , seizures can be fatal

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20
Q

manifestations of TURP can be

A

circulatory fluid overload, water intox, toxicity from soluite in irrigating fluid

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21
Q

electrolyte solutions do what to electrocautery current

A

disperse so we have to use water-better visibility- hypotonicity lyses RBC

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22
Q

water can cause acute water intoxication so only for TUR of bladder tumors , for the TURP we use

A

slightly hypotonic nonelectrolyte irrigating solutions such as glycine 1.5% or sorbitol and mannitol .54%

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23
Q

you can have absorption of water because these fluids are hypotonic and high pressure irrigation can cause

A

absorption of solutes

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24
Q

absorption of TURP irrigation fluid depends on duration of resection and pressure of irrigaiton fluid. 1 hour and 20 mL/min absorbed. which can lead to

A

pulmonary congestion or pulmonary edema, in patients with limited cardiac reserve

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25
Q

hyponatremia-get symptoms when less than 120 meq/L, and below 100 you can get

A

acute IV hemolysis

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26
Q

can also absorb solutes-causing ______ with glycine solutions-circulatory depression and CNS toxicity

A

hyperglycemia

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27
Q

glycine is a

A

inhibitory neurotransmitter in CNS-causes blindness following TURP

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28
Q

degrading glycine gives hyperammonemnia after TURP where values reach

A

500 normal is 5-50

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29
Q

mannitol can make volume overload worse, and soribol and dextrose can cause

A

hyperglycemia

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30
Q

TURP treat hypoxemia, hypoperfusion, eliminate absorbed water

A

fluid restriction and IV furosemide, hypertonic saline, seizure with versed, phenytoin, ett intubation until metnal status normalizes

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31
Q

warm irrigating solutions for patients-hypothermia causes post opp shivering which may

A

disloge clots and promote post opp bleeding as well as physiological stress to patients with coexisting cardiopulmonary disease

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32
Q

less than 1% you can get ___ ___ from TURP

A

bladder perforation from rectoscop or overdistension of bladder with irrigation fluid

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33
Q

if you have perforation what would you suspect

A

sudden hypotension or hypertension, particulalry with acute , vagally mediated bradycardia

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34
Q

disseminated intravascular coagulation has been reported with ____

A

TURP-release of thromboplastins from prostate tissue into circulation during procedure-blood clots can form and block blood flow to tissues

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35
Q

TURP can cause dilutional ____

A

thrombocytopenia

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36
Q

if you have fibrinolysis you can treat with E-aminocarpoic acid (amicar) dose

A

5g and 1 g/h

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37
Q

to treat DIC , you have to give heparin in addition to replacing ___

A

clotting factors and platelets-consult hematologist

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38
Q

prostate is often colonized with bacteria nad may harder chronic infection so we worry about

A

baceria getting into blood stream- bacteremia following transurethra surgery is common- can lead to septicemia or septic shock

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39
Q

give prophylactic antibiotic before or TURP to decrease likelihood of

A

bactermeic and septic episodes- can easily get into venous sinuses, septicemia or septic shock

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40
Q

TURP can be done under

A

spinal, epidural anesthesia, with a T10, or general anesthesia

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41
Q

regional anesthesia for TURP may reduce incidence of

A

postop venous thrombosis, less likely to mask symptoms and signs of TURP syndrome or bladder perforation

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42
Q

acute hyponatremia from TURP syndrome

A

delay emergence from general anesthesia

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43
Q

metastaic disease involving lumbar spine is contraindication to

A

spinal or epidural anesthesia

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44
Q

what is best monitor for detecting early signs of TURP syndrome and bladder perfoation

A

evaluation of mental status

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45
Q

tachy or decrease in arterial oxygenation, or ischemic ecg changes may be early sign of

A

fluid overload

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46
Q

temperature monitoring to detect

A

hypothermia

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47
Q

blood loss for TURP is about 200-300 cc or

A

3-5 mL/min

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48
Q

might see post opp hemodilution from absorption of

A

irrigation fluid

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49
Q

what are the factors associated with intraop blood transfusion

A

procedure duration longer than 90 min and resection of 45 g of prostate tissues

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50
Q

ureteroscopy with stone extraction, stent placement, and intracorpeal lithotripsy and with medical expulsive therpay (MET) are firstl line therapy for

A

treatment of kidney stones

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51
Q

extracorporeal shock wave lithotripsy ESWL for stones that are

A

4 mm to 2 cm, percutaneous and laparoscopic nephrolithotomy for larger or impacted stones

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52
Q

you can use MET , medical expulsive therapy for acute episodes of urolithiasis -stones 10 mm in diamerter- so you administer

A

alpha blockers tamsulosin (flowmax), doxazosin, terazolis or calcium channel blockers nidfedipine-lessens pain and inc rate of stone expulsion from several days to several weeks

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53
Q

during ESWL-repetitive high energy shocks (sound waves) generated and focused on stone-to break it. water or conductive gel serves to

A

couple generator to the patient. waves dont damage the tissue because tissue and water have the same acousitic density. difference in density with stone-creates shear and tear forces

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54
Q

stents are placed cystoscpically (eswl) prior to the procedure to allow the

A

stones to be turned into small pieces down the urinary tract

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55
Q

air-tissue interface-lung and intestine are ___ for ESWL

A

contraindication- can cuase tissue destruction, need to position the patient away from lungs and intestine for sound waves

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56
Q

other contraindications for eswls are

A

urinary obsturction below stone, untreated infection, bleeding diathesis, and pregnancy

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57
Q

relative contraindication for eswl

A

aortic aneursym or orthopedic prosthetic device

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58
Q

ecchymosis, bruising, or blistering of skin over treatment site is not uncommon for eswl and you can also get hematoma-explains post opp dec in

A

hematocrit

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59
Q

patient with history of arrhytmias or those with a pacemaker or internal cardiac defibrillator ICD may be at risk for

A

arrhytmias induced by shockwaves during eswl

60
Q

arrythmias during eswl you should

A

synchronize the shockwaves with the ECG r wave to decrease the incidence of arrhymias.

61
Q

shockwaves should be ___ after the R wave to correspond with the ____ for eswl

A

20 ms after the R wave, ventricular refractory period

62
Q

asynchronous deliver of shocks may be safe in patients without heart disease-but can damage

A

pacemaker and ICD

63
Q

if you have immersion during eswl 36-37 C results in vasodilation that can lead to hypotension but arterial pressure increases becuase venous blood is redistributed centrally. ___ rises and CO decreases

A

SVR decreases. if you have inc in volume and SVR you can get CHF in ppl with marginal cardiac reserve. inc in blood volumea-reduces frc by 30-60% may predispose some patients with hypoxemia

64
Q

pain from lithotripsy is from dissipation of a small amount of energy as shock wave enter the body through the

A

skin(localized on it so pain is proportionate to shock wave intesity ) newer ones have lower intensity shock waves so you need only light sedation

65
Q

for older eswl with water bath-continuous epidural anestheai, or regional with sedation, T6 sensory level ensures adequate anesthesia because renal innervation is dervied

A

from T10-L2

66
Q

use saline instead of air during epidural as air in epidural space can dissipate shock waves and promotie injury to

A

neural tissue

67
Q

epidural vs. spinal for eswl

A

with spinal you have less control over sensory level, uncertain duration of surgery

68
Q

disadvantage for regional for eswl

A

you can move the stone in and out of wave focus with excessive diaphragmatic excursion during SV-ask patient to breathe more rapid and shallow

69
Q

can get brady due to high sympathetic blockade-when shcokwaves are coupled to ecg-give glyco to

A

accelerate procedure

70
Q

light IV sedation with versed and fentanyl for modern low energy lithotrupsy, and deeper with

A

low dose propfol infusions may also be used

71
Q

even with R wave syrnchornized shocks Supraventrical arrhytmias can occur and fluid management for ESWL-is

A

generous- initial bolus and 1000-2000 cc of LR with furosemide to maintain brinsk urinary flow and flush stone debris and blood clots, patients with poor cardiac reserve require more conservative fluid therapy

72
Q

open procedures for kindey stones in upper ureter and renal pelvis and nephrectomies for non malignant disease are carried out in

A

kidney rest position-lateral flexed position

73
Q

lateral position- axiallary roll placed beneath the depednetn upper chest to minimize the risk of

A

brachial plexus injury

74
Q

latearl flexed position you get adverse

A

respiratory and circulatory effects

75
Q

lateral flexed position- frc is reduced in depedent lung and inc in nondepedent, but depedent receives more blood flow, but nondepdent receives greater ventilation presdisposing patient to

A

atelectasis in the depedent lung and to shunt induced hypoxemia, inc in DS ventilation-from inc gradient of co2-arterial to end tidal

76
Q

elevation of kidney rest can dec VR to heart by compressing IFC, venous pooling in legs potentiates-lateral flexed position

A

anesthesia induced vasodiation

77
Q

may urological procedures-

A

patient is in hyperextended supine position

78
Q

adenocarcinoma of prostate most common nonskin cancer in

A

men

79
Q

patients with prostate c ancer- may present to the OR for laparoscopic or robotic prostatectomy with pelvic lymph node dissection, radical retropubic prostatectomy with lymph node dissection or salvage prostatyectomy , or bliateral orchiectomy

A

for hormonal therapy

80
Q

failure of radiation leads to

A

radical retropubic prostatectomhy, get rid of eminal vesical, ejaculatory ducts, part of bladder neck, nerve sparing technique-help preserve sexual function

81
Q

after a prostatectomy-the bladder neck is anastomosted to the urethra over an indwelling urinary catheter-surgeon asks for indigo carmine for visualization of

A

ureters -can be associated with htn or hypotension

82
Q

radical retropubic prostatectomy you can do under general or regional with sedation because of position. neuraxial is at the

A

T6 level

83
Q

post opp complications include

A

hemorrhage, deep vein thrombosis, PE, injuries to obturator nerve, ureter and rectom, urinary incontinence nad impotenct

84
Q

extensive surgical dissection around pelivc veins inc risk of

A

thromboembolic complications

85
Q

toraldol used as an anaglesic adjuvant-dec opiod requirements improve analgesia and promote earlier return of bowel function without

A

increasing transfusion requirements

86
Q

for epidural post opp pain in the setting of anticoagulation therapy you have to worry aboutr

A

risk of epidural hematoma

87
Q

avoid nitrous in laparascopic to prevent

A

bowel distension

88
Q

complications with robot assisted radical prostatectomy are steep tberg

A

upper airway edema, post extubation resp distress post opp visual loss-ischemic optic neuropathy or retinal detachemnt or brachial plexus injury

89
Q

bilateral orchietomy is perforemd for

A

hormonal control of metastatic adenocarcinoma of prostate-, 20-45 mins local or gen lma

90
Q

there is assocation between what and bladder carcinoma

A

smoking so you can have coesitent coronary artery and chronic obstructive pulmonary disease in these patients

91
Q

transurethra resection of bladder tumors is carried out via cysto for low grade noninvasive tumors

A

TURBT

92
Q

lateral bladder tumors mya lie near the obturator nerve so if you use spinal or genral anesthesia without paralysis evey use of cautery recsetoscope results in

A

stimulation of the octurator nerve and adduction of legs

93
Q

TURBT vs TURP

A

rarely assocated with absoprtion of irigating solution- TURBT performed with gen anesthesia with paralysis

94
Q

radical cystectomy

A

-all anterior pelivc organs are removed bladder prostate and seminal vesicales and bladder uterus and cervic ovaries and part of anterior vaginal vault removed in females, pelivc node diessction and urinary diversion

95
Q

radical cystectomy lasts 4-6 hours, associated with blood transfusion, Gen ett with paralysis, you can use controlled ___ to reduce intraop blood loss and improve surgical visualzation

A

hypotension

96
Q

can use general with a spinal or epidural for radical cystectomy because of

A

dec gen anestheic requiremtns , highly effect post op analgesia, can faciltate induced hypotension

97
Q

with radical cystectomy- UO should be monitered as urinary path is interrupted early during

A

most procedures

98
Q

urinary diversion-immediately following a radical cystectomy-implant a ureter into a segemnt of bowel so anesthetic considerations here are to

A

keep patient well hydrate and maintianing a brisk urinary output once the ureters are opened

99
Q

neuraxial anesthesia- unupposed parasymapthetic activity due to sympathetic blockdade -causes

A

hyperactive bowel that makes construction of a continent ileal reservoir difficult-paperine, glyco or glucagon alleviates this problem

100
Q

slow urine flow can produce significat

A

metabolic disorders, jejunal conduits-hyponatremia, hypochloremia, hyper K, and metaboolic acidosis

101
Q

colonic and ileal conduits may be assoicated with

A

hyperchloremic metabolic acidosis, use temporary uretreral stents and maintenance of high urinary flow

102
Q

testicular tumors are either seminomas or nonseminoams-inital treamtnet is radical inguinal orchietomy

A

morbidity from preop chemo and radiation-bone marrow suppression, renal impariment specific organ toxcitity

103
Q

radical orchietomy can be done under regional and general and you can get

A

reflex brady from traction of spermatic cord

104
Q

retroperitoneal lympph node dissection what occurs

A

all lypmathic tissues is removed in area, and sympathetic fibers are disrupted so you have loss of normal ejaculation and infertility but there is modified technique that can help maintian fertility

105
Q

patients receiving ____ preop may be at risk for oxygen toxcity and fluid overload and for developing pulmonary insufficiency or acute resp distress syndrome post op (retroperitoneal lymph node dissection)

A

bleomycin, use lowest inspired concentration of oxygen compatible with oxygen sat above 90%-use peep of 5-10

106
Q

retroperitoneal lymph node diessection worry about fluids–maintain .5 mL/kg/hr greater with colloid because of

A

evaporate and redistributive fluid losses-third spacing with open RPLND,retraction of IVC results in arterial hypotension

107
Q

post opp pain with retroperitoneal lympph node diession- severe -so use

A

continuos epidrual analgesia, dilaudid,

108
Q

artery of _____ is responsible for most of the arterial blood to the lower half of the spinal cord arises on the lft side

A

adamkiewicz, so in RPLND-ligation of intercostal arteries during left sided dissections has rarely resulted in paraplegia-document nerve function

109
Q

unilateral sympathectomy following modified RPLND usually results in ipsilateral leg being ____ than contralateral one

A

warmer, post opp -severe bladder spasm pain

110
Q

renal cell carincoma is assocated with

A

paraneoplastic syndromes, erythrocytosis, hypercalcemia, hypertension, and nonmetastyatic hepatic dysfunction

111
Q

renal cell carcinoma-10% of patients have classic triad of

A

hematuria, flank pain and palpable mass. there are only symtoms when tumor has grown in size

112
Q

in 5-10% of patients renal cell carcinma extendes into the renal vein and IVC as a thrombus-so use

A

CT , MRI or arteriogram, preop arterial embolization may shrink tumor mass and reduce operative blood loss

113
Q

preop evalu of renal cell carcinoma

A

searching for presence of coesxiting systemic disase,degree of renal impairment, planning anesthetic managemnet by scope of anticipated surgical resection

114
Q

preexisting renal impariment depdonds on tumor size as well as underlying disorders like

A

HTN and diabetes, smoking risk factor-coaranry artery and Chronic obstrucive lung disease

115
Q

when large tumor is sected do preop blood transfusion to

A

10 g /dL

116
Q

for radical nephrectomy-kidney adrean bland and fat are removed-gen ett with epidural-considerations

A

tumors are vascular so potential for extensive blood loss, tumor are large. need TEE for extensive vena cava thrombus/ use only brief periods of controlled hypotension-reduce blood loss and it can impair function in contralateral kidney

117
Q

reflex renal vasoconstriction you can get in unaffeted kidney-can can get post opp renal

A

dysfucntion, maintina urine greater than .5 ml/kg/hr

118
Q

radical nephrectomy-uses general with epdiural anesthesia-but LA from epidural should be postponed until risk of blood loss has

A

passed because sympathetctomy from LA potetional the hypotensive effect of hemorrhage, lots of post opp pain use epidural

119
Q

radical nephrectomy with tumor thrombus extending into IVC- thoracoabdominal approach allows the urse of cardioulmonary bypyass when necessary. 3 levels

A

level 1-inferior VC below liver,up to the lver but below diaphrapm level II, level III or above diaphram into right atrium

120
Q

radical nephrectomy with thrombus-VQ scan may detect preexisting pulmonary embolization of thrombus and use ___ to discover where thrombus is

A

TEE

121
Q

radical nephrectomy level II or three require 10-15 units of PRBC, platelets , FFP and cryo, cvp to

A

prevent dislodgment and embolization of tumor thrombus

122
Q

a high central venous pressure in setting of sign caval thrombus reflects the

A

degree of venous obstruction

123
Q

complete obstruction of vena cava-inc operative blood loss-diatled venous collaterals and yo uare sig risk for

A

pulmonary embolism of tumor

124
Q

tumor embolism signs

A

suprventricular arrhytmias, arterial desat, profound hypotension-usre TEE

125
Q

cardiopulmonary bypass may be used when tumor occupies more than 40% of RA and cannot be pulled back into

A

cava

126
Q

for patients undergoing renal transplantation the preop serum K should be below 5.5 meq/L and existing coagulaptheis should be corrected. this is because

A

hyperkalmeia has been reporeted after release of vascular clamp following completion of the arterial anastomosis, particularly in pediatric and other small patientions. cause from relase of K in preservative solution

127
Q

renal transplant-heparin given before clmaping of iliac vessels, and IV mannitol adminsitered to the recipient-helsp to get osmotic diuresis following reperfusion. immunsuppression given on day of surgery

A

most ranspalntas are perfoemd with gen anesthes alouth spinal and epidural are also utilized,

128
Q

which muscle relaxants to use that are not depdent upon renal excretion for elmination

A

cisatracurium and roc, vec only has modest prolongation

129
Q

central venous cannulation can ensure adequate hydration while avoiding fluid overload also good for

A

infusion after the first few daysa after transplant,

130
Q

good urine flow after arterial anastomosis generaly indicates

A

good graft function, but can get oliguric phase before diuretic phase if graft ischemic time was prolonged- adjust fluid therapy-furosemide or additional mannitol

131
Q

what will help avoid hyper kalemia

A

donor kidney washout of perservative solution with ice cold lactated ringer’s solution before vascular anstomosis

132
Q

hyper K from peaking of on the ECG

A

T wave

133
Q

hypotension after TURP can be

A

hemorrphate, TURP syndrome, bladder perforation, MI or ischemia, septicemia and DIC

134
Q

hypotension compromises coroanry perfusion (history of CAD) and shivering increases

A

myocardial oxygen demand

135
Q

comintinous bladder irragation systme placed

A

after the TURP procedure-brisk hemorrphage-grossly bloody drainage, drainage may be scant-clots block drain-so irrgate the catheter

136
Q

hypovolemica patients have dec

A

peripheral pulsens, extremities are cool, and may be cyanotic, poor perfusion is consistent with hemorrhage , bladder perforation, DIC, MI or infraction

137
Q

full bounding bounding peripheral pulse with warm extremeities-suggests

A

septicemia

138
Q

sighs of fluid overload

A

jjugulcar venous distension, pulmonary crackles and S3 gallop

139
Q

fluid overload is more consistent with TURP synbdrome but can be

A

seen in MI or ischemia

140
Q

rigid and tender or distended abdoment

A

suggestive of performation and should prompt immediate surgical evaluation

141
Q

___suggested by diffuse oozing, fibrinogen and fibrin split product measuremnets

A

DIC

142
Q

temeperatuire does not excluse spepsis-general anesthesia messes with temeprature e

A

regulation

143
Q

anestyhetics alter normal behavior of hypothalamic thermoregulatory centerers in the brain while infectious agents circulating toxins or immunie reactus cause relase of

A

cytokines interleukin 1 and tumor necrosis factor-stimulate the hypothalamus to synthesis prostaglandin PG E2- which activate neurons responsible for head producitng resulting in intense shivering

144
Q

shivering inc metabolic oxygen demand

A

100-200% and co2 production, so CO and MV must increase, give oxygen to prevent hypoxemia, meperidine 25-50 mg, chlorpomazine 10-25 mg and butorphanol 1-2m g (act on temerapture regulators in hypothalamus_

145
Q

shivering associated with sepsis or immune reactions can aslo be blocked by inhibitors of prostaglandin synthetase such as

A

aspirin, acetaminophen,NSAID as well as glucorotiocids. IV tylenol good because does nbot affect platelets

anesthesia for genitourinary surgery (2 decks)

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