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Principles of Anesthesia I > E3 > Flashcards

E3 Flashcards

1
Q

When would an esophageal obturator/combitube be used

A

 Failure to intubate
• introduced as a sub for intubation
• esp by EMT/paramedics

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2
Q

What is a combitube and the functions of it’s parts.

A

 Double lumen blind insertion device
• distal lumen = intended to enter the esophagus
• proximal lumen = should terminate at tracheal level for pt ventilation
 Allows for decompression of gastric contents
 May be used with PPV
• Up to 50cm H2O for short periods

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3
Q

Types of manufactured rigid DLs

A
  • single piece

* detachable blade/handle

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4
Q

What are the components of a rigid DL

A

Light source
Handle
Blade

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5
Q

Describe the light source for the laryngoscope

A

• light bulb or fiberoptic

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6
Q

What is the design of the laryngoscope handle? How is it held?

A
  • part held in LEFT hand
  • provides power for light
  • most use disposable batteries
  • MOST form right angle to blade when ready for use (when blade open)
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7
Q

What is the laryngoscope blade purpose and it’s design.

A
  • inserted into mouth
  • different sizes
  • increasing number=increased size
  • tongue=manipulate and compresses soft tissue for better insertion
  • directly or indirectly elevates epiglottis
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8
Q

Design and sizing of macintosh blade

A

• Tongue has gentle curve
 anatomical- Tip is in and visualize vallecula
 b/c epiglottis is pulled forward

Size:
• #3 and #4 = useful for adults

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9
Q

advantage and disadvantage of the macintosh blade

A

advantage
• Makes intubation easier
 b/c blade requires mouth opening due to blade size

Disadvantage
• Can cause greater c-spine movement than with Miller

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10
Q

When a macintosh blade is used, how is it inserted and what is visualized

A

View of epiglottis with macintosh
 After epiglottis is visualized tip advanced into vallecula
 Pressure at right angle to blade to move base of tongue and epiglottis forward
 Can be used like Miller to elevate tip of epiglottis

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11
Q

Design and sizing of the miller blade

A

Tongue is straight
 with slight upward tip-
 Blade goes over epiglottis and lifts it

Sizing:
• #2 and #3 for adults

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12
Q

Advantages of the miller blade

A

 Force, head extension, and c-spine movement is less

 Great for smaller mouths and longer necks

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13
Q

What structures are visualized and how is the miller used to do so.
Complications of being too far or withdrawing?

A

View of epiglottis with miller
 Blade lifts epiglottis

If inserted too far
 it elevates larynx or esophagus

If withdrawn too far
 epiglottis flips down and covers glottis

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14
Q

Technique for laryngoscope insertion including position and advancement

A
  • “sniffing” position
  • 35° cervical flexion and 85° extension of atlanto-occipital level
Insertion
•	right hand opens mouth “scissor”
•	Insert blade on right side of mouth
•	Advancing = keeps tongue to left and elevated
•	Do not rick back and damage teeth
•	View epiglottis
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15
Q

What is the atlanto-occipital level and significance for intubation

A

 imaginary line btwn external auditory meatus and sternal notch
• 85° extension of atlanto-occipital level

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16
Q

Why is the scissor technique used with DL and what is most important to note with using this technique

A
  • keeps lips free
  • to accommodate blade insertion
  • right hand opens mouth “scissor”
  • Remove hand once blade inserted
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17
Q

What may be require for a difficult airway

A

• may require the use of a flexible fiberoptic scope

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18
Q

What is the design and advantage of the fiberoptic scope for difficult airway

A

Design
• with glass fiber bundles in the scope
• a camera view

Advantage
• allows identification of landmarks
• facilitates intubation

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19
Q

How is the fiberoptic scope used for a difficult intubation

A
  • neutral position
  • need a fiberoptic scope oral airway
  • can be awake or “asleep
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20
Q

Why is positioning important for intubation? How is optimal position achieved?

A
  • Aligning axis to get straight view down oropharynx through VCs
  • Can’t just raise HOB b/c Axis won’t be aligned

Achieved:
• Use something that isn’t compressible (blankets/sheets)
–Sniffing position = 35deg cervical flexion and 85 deg extension of AO level

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21
Q

What is the design and purpose of the bullard laryngoscope? When may it be useful?

A

Parts/design:

  • Working port for suction
  • Eye piece to indirectly view cords
  • ETT fastened to laryngoscope
  • Light source/handle is upright

Purpose:

  • To indirectly view cords
  • May be useful in small mouths that don’t open well
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22
Q

What were advantages of the bullard (3)

A
  • helpful in difficult intubations
  • causes less cervical spine movement than direct laryngoscopy
  • more rugged than fiberoptic scope
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23
Q

What were disadvantages of the bullard (5)

A
  • requires experience
  • somewhat expensive (back in the day)
  • cleaning more involved
  • laser ETT and double lumen will not fit
  • has largely been replaced with video laryngoscopes
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24
Q

What is the design and purpose of the Wu Scope? How was insertion achieved?

A

Design
• Rigid, tubular blade and flexible fiberscope
• Eye piece at the end
• ETT and suction thread through 2 blades

Insertion:
• Insert like OPA- in midline
• Back blade removed first
• then remainder of unit second

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25
Q

Advantages of the Wu scope (5)

A

Advantages
• can place double lumen
• fiberoptic lens is protected from blood, secretions, and redundant tissue
• no stylet is needed
• minimal jaw opening is necessary
• better hand/blade angle for large breasts or barrel chests

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26
Q

Disadvantages of the Wu scope (3)

A

Disadvantages
• high initial cost
• requires experience
• have been largely replaced by video laryngoscope

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27
Q

What are examples of rigid indirect laryngoscope

A

Bullard
Wu
Shikani

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28
Q

What is the design of the shikani optical stylet

A

Lighted stylet w/ malleable distal tip
Has an eye piece
O2 port

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29
Q

How is the shikani used for intubation. Sizing.

A
  • Neutral position inserted midline
  • Stainless steel stylet advanced INTO trachea
  • light anteriorly at all times to avoid injury

Sizing:
• available in adult and peds sizes

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30
Q

Advantages of shikani optical stylet

A 
Difficult airway 
Not as invasive
Easy to use
O2 port
Didn't require special patient positioning
Smaller profile
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31
Q

Disadvantage of the shikani optical stylet. How is this prevented?

A

Stainless steel stylet
Very careful when advancing into trachea to avoid injury

Prevented:
maintain light anteriorly to avoid injury

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32
Q

How is the lightwand different than the shikani

A

Shikani
has an eye piece
Uses indirect visualization

Lightwand
BLIND

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33
Q

What are advantages of video laryngoscopes (6)

A
  • magnified anatomy
  • rigid scopes have angled blades to mimic laryngoscopes
  • operator and assistant can see
  • may result in decreased cervical spine movement
  • further distance from infectious patients
  • demonstrates correct technique in legal cases

FYI-traditionally mac blades

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34
Q

Limitations of the video laryngoscope (3)

A
  • requires video system
  • portability varies
  • If intubation is difficult must withdraw laryngoscope slightly***
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35
Q

When using a glidescope, what should the anesthetist do if intubation is difficult

A

Withdraw the tip of the laryngoscope slightly

To have an easier passage of ETT

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36
Q

In a pt with a mouthful of rotten teeth, what would be the best method of intubating.

A

Glidescope w/ thinner cover/profile and it is plastic

instead of stainless steel DL blade

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37
Q

What is the most frequent anesthesia-related claaim

A

Dental injury

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38
Q

What is most likely damaged and how is this prevented

A

Most likely damaged:

  • upper incisors
  • Teeth restored or weakened

Prevention:

  • Teeth protectors
  • Stay off the teeth
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39
Q

Describe how DL can contribute to cervical spine cord injury

A

 aggressive head positioning esp neck extension
 manual in-line stabilization
• do not rely on cervical collars

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40
Q

What other structures may be damaged during DL?

A

 abrasions/hematomas
 lingual &/or hypoglossal nerve injury
 arytenoid subluxation
 TMJ dislocation

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41
Q

What are complications of laryngoscopy

A

Dental injury
Cervical spinal cord injury
Damage to other structures (lingual/hypoglossal nerve injury, TMJ dislocation etc)
Swallowing/aspirating foreign body

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42
Q

What are the most prominent teeth to be injured during DL

A

Upper = R 7-10 L

Lower = R 26-23 L

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43
Q

What are reasons that breathing systems change resistance

A
  • ID of tube
  • tube length
  • configuration changes
  • connectors
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44
Q

Describe the tracheal tube design

A 
Internal and external walls circular 
•	decreases kinking
May shorten at machine end
Patient end has slanted bevel
•	helps view larynx
Murphy eye
•	provides an alternate pathway for gas flow
Pilot cuff w/ 8-10 ml air injected
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45
Q

What are the advantages of the RAE tubes

A 
•Facilitate surgery around head and neck
•Temporarily straightened during insertion
•Larger diameter
	longer distance from tip to curve
•Cuffed or uncuffed
•Easy to secure
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46
Q

What are disadvantages of the RAE tube

A
  • Difficult to pass suction/scope

* Increases airway resistance

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47
Q

In what procedure may an oral rae tube

A

tonsillectomy

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48
Q

When would a spiral embedded tube be most useful

A

in head and neck surgeries when there is a lot of movement

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49
Q

What are advantages and disadvantages of the spiral embedded tubes

A

Advantages
• Useful when tube is likely to be bent or compressed
• Good for head and neck surgeries

Disadvantages
• Need a stylet b/c tube is more flexible
• Cannot be shortened
• Have been damaged when biting

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50
Q

What is the design of laser tubes and for what procedures are they used?

A
  • Stainless steel or wrapped
  • Reflects laser beam away from gases
  • Cuffs filled with methylene blue
  • colored saline

Use:
Laser surgeries like
head and neck tumor removal
tracheal stenosis

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51
Q

Why is a reflective ETT important in laser surgery

A

To prevent fire b/c of abundance of O2

Laser can ignite an airway fire

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52
Q

What are the disadvantages of laser tubes

A

Disadvantages
• Stiff and rough (SS)
• Difficult to pass stylet through (SS)
• Less resistant to laser if blood on tube (W)

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53
Q

What are laser tube cuffs filled with an why?

A

Filled with:
Methylene blue or colored saline

Why:
So you can see if there is a cuff leak/perforation from the laser
Then tube exchange needs to happen

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54
Q

What will the anesthetist do with gases when lasers are used

A

Low FiO2

No N2O

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55
Q

Manufacturing requirements for tubes (10)

A 
Low cost
Lack of tissue toxicity
Easy sterilization (if not disposable)
Non-flammable
Smooth, non-porous surface
Sufficient body
Sufficient strength
Conforms to anatomy
Lack of reaction w/ anesthetic agent and lubricants 
Latex free
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56
Q

What are safety standards for tube markings (5)

A
  • Words= oral or nasal or oral/nasal
  • name of manufacturer
  • graduated markings in centimeters from patient end
  • cautionary note=single use only
  • radiopaque marker at patient end (to be visible on xray)
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57
Q

Describe the design of tracheal tube cuffs

A

 Inflatable balloon near patient end of tube
• Will sit just past the VCs (distal to cords)
 Resistant, thin, soft, pliable

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58
Q

What are the cuff requirements for tracheal tube placement and inflation. Considerations when using nitrous.

A

 Must not herniate over murphy eye or bevel of tube
 Cuff pressure = 18-25 mm Hg; usually 8-10 mL of air
 Monitor cuff pressure frequently if using nitrous as this causes cuff inflation/expansion

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59
Q

How long before tracheal necrosis d/t hyperinflation of cuff

A

30 min

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60
Q

What is the design of high-volume, low-pressure cuffs of tracheal tubes.
What types of tubes?

A

• Thin compliant wall
 Occludes trachea w/o stretching tracheal wall
 Area of contact much larger
 cuff adapts shape to tracheal wall shape

Tube types:
Regular ETT

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61
Q

What are the advantages and disadvantages of the high-volume, low-pressure cuff

A

Advantages
 easy to regulate pressure
 pressure applied to trachea less than mucosal perfusion pressure

Disadvantages
 cuff is more likely torn during intubation (esp w/ prominent incisors)
 more likely to have a sore throat
 may not prevent fluid leakage
 easy to pass NGT, esophageal stethoscopes around cuff

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62
Q

What is the design of low-volume, high-pressure cuffs of tracheal tubes.
What types of tubes?

A

design:
• Has small area of contact with trachea
 Requires large amount of pressure to achieve a seal
 Distends and deforms the trachea to a circular shape

Examples:
 Trach, double-lumen tube—bronchial cuff (3 ml), combitube–tracheal cuff

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63
Q

What are the advantages and disadvantages of the low-volume, high-pressure cuff

A

Advantages
 better protection against aspiration
 maybe lower incidence of sore throat (smaller area, less contact irritation)

Disadvantages
 pressure exerted on trachea probably above mucosal perfusion pressure
 Can increase chance of necrosis
 should be replaced if postoperative intubation is required (tube exchange)

Check cuff pressure regularly and make sure it is not hyperinflated

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64
Q

What populations receive cuffed vs uncuffed tubes

A 
cuffed = adults
uncuffed = peds
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65
Q

Why are cuffed tubes used in adults

A
  • accurate end-tidal gases
  • decreased aspiration
  • decreased pollution
  • decreased risk of fire
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66
Q

What is the best indicator for ETT size and what are not

A

best = gender
female 7.0, male 8.0

Not indicators
age, race, height, weight, BSA

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67
Q

What is the guide for sizing ped tubes

A

(age/4)+3

Not on test…

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68
Q

Why are uncuffed tubes routinely used in peds

A

Airway anatomy is different

Cricoid is narrowest part vs adults

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69
Q

How are tidal volume and gas maintained when using uncuffed tubes for peds

A

Make sure airway pressure is not too high
maintain < 20 cmH2O to prevent leak

Smaller volumes, higher RR

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70
Q

What can cause changes in cuff pressure

A
  • Use of N2O (check pilot cuff pressure)
  • Hypothermic cardiopulmonary bypass (smaller volume, poor seal)
  • Increases in altitude
  • Coughing, straining, changes in muscle tone
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71
Q

What are the common controversies in the field concerning tracheal tube care and insertion

A

 Stylets??
 Securing??
 Bite blocks/airways while intubated??
 Is it bad to intubate the esophagus??

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72
Q

What are some ETT complications (6)

A 
Trauma
Esophageal intubation
Inadvertent bronchial intubation
Fluid accumulation above the cuff
Upper airway edema
VC granuloma
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73
Q

What is the biggest risk of intubation the esophagus

A

not identifying it and not correcting it

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74
Q

What can lead to trauma from ETT insertion and how can this complication be prevented

A

Causes:
 associated with excessive force, repeated attempts
 varies with skill, difficulty of airway, amount of muscle relaxation

Prevention:
	keep stylet INSIDE tube
	use vasoconstrictors for nasal intubation and pre-dilate (Afrin)
	Make sure pt is ASLEEP
	Do the SWEEP
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75
Q

How can vasoconstriction and pre-dilation be addressed w/ nasal intubation

A

vasoconstriction:
Afrin use

Pre-dilate:
make nare bigger
gradual increase of nasal trumpet in nare w/ adequate lubrication
Can help determine which nare to use

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76
Q

How can esophageal intubation be determined (5)

A 
Directly visualize it's not in VCs
No chest wall motion
EtCO2--waveform may be present initially
Auscultate = no BS, epigastric sounds
Oxygenation = not maintained
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77
Q

When is inadvertent bronchial intubation most likely to occur? What can it lead to?

A

Occurs:

  • Most frequent in emergencies and peds
  • When distance to carina decreased (trendelenburg and laparoscopy)
  • Dislodged w/ instrumentation (GI/Cath lab w/ camera)

Leads to:
Atelectasis

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78
Q

What should be the depth marking for ETT in females, males and peds

A

Adults:
female = 21 cm @ teeth
Male = 23 cm @ teeth

Peds:
(age/2)+12 cm
PEDS NOT ON EXAM

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79
Q

How can fluid accumulation above the cuff complicate ETT use? Why is this dangerous.

A

 blood can accumulate and clot in trachea
 difficult to reach with yankauer suction

Can lead to laryngospasm upon extubation

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80
Q

Where can airway edema occur when using ETT

What populations are most affected and why

A

anywhere along path of tube

 dangerous in young children
• cricoid cartilage completely surrounds subglottic area
• peak incidence between 1-4 y/o

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81
Q

When are airway edema signs most visible?

How can it be prevented?

A

 earliest signs 1-2 hrs postop up to 48 hours postop

Prevention:
Avoid irritating stimuli, URI
adequate anesthetic depth (decrease airway stimulation)

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82
Q

How can VC granulomas occur w/ ETT use

What are the signs/symptoms

A

 trauma, too large ETT, infection, excessive cuff pressure on or around VCs

S/Sx
 persistent hoarseness, fullness, chronic cough, intermittent loss of voice

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83
Q

What population may be more prone to forming VC granuloma.

How is it treated?

A

Population:
 common in adults; females

Treatment:
 laryngeal evaluation, voice rest

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84
Q

What is a bougie and when is it used

A

It is:
 polyester base with resin coating
 distal end angled 30-45 degrees
 introduced with tip anteriorly

Use:
 for blind intubation
 if glottic exposure is absent
 when ETT passage is difficult (i.e. anterior VC position)

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85
Q

When are magill forceps used?

What are complications of magill forceps use

A

Primarily during nasal intubation
-To direct tube into larynx

Complications:

  • Damage to cuff
  • Lodge in murphy eye
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86
Q

What airway adjuncts should be readily available in every room.

A

Bougie

Magill forceps

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87
Q

When is lung isolation indicated?

A

Thoracic procedure
• deflated lung increases safety profile and surgical exposure

Control of contamination or hemorrhage
• can prevent material in 1 lung contaminating other
• allows one lung to be ventilated while other hemorrhages

Unilateral pathology
• excludes fistulas, ruptured cysts or other issues with the diseased lung
• while allowing unilateral ventilation

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88
Q

Difference in right and left lung anatomy and how intubation is affected.

A 
Right mainstem
•	shorter, straighter (25° takeoff)
•	larger diameter
•	RUL takeoff very close to origin
Left mainstem
•	45° takeoff
•	LUL takeoff more distal (5 1/2 cm)
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89
Q

What determines if double-lumen tube is right or left

A

The termination point of the bronchial lumen

Right tubes have 3 ports for ventilation in the bronchial lumen
-To ventilate the RUL

Left tubes have 2 ports for ventilation in the bronchial lumen

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90
Q

What are the double-lumen tube types and sizes?

Which is primarily used?

A

Double-lumen tubes
• Adult sizes: 35, 37, 39, 41
• Pediatric sizes: 26, 28, 32

Primarily we use LEFT DLT

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91
Q

What procedures would a double-lumen tube be used?

A
  • Pneumonectomy
  • left lung transplantation
  • left mainstem bronchus stent in place
  • left tracheo-bronchus disruption
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92
Q

When is a right double-lumen tube used?

A 
when performing the following procedures on the left lung
•	Pneumonectomy
•	left lung transplantation
•	left mainstem bronchus stent in place
•	left tracheo-bronchus disruption
(don't need to memorize surgeries***)
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93
Q

How are double-lumen tube placement confirmed

A

Like we confirm ETT intubation, then…
 BOTH lungs isolated
 fiberoptic examination performed

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94
Q

What are complications with DLT placement

A

Tube malposition:
 Unsatisfactory lung collapse
• Bronchial lumen in wrong mainstem- reinsertion (R vs L)
• Tube too proximal in airway- correct with fiberoptic

Hypoxemia:
	malpositioned tube- reinsertion
	patient comorbidities
•	may need PEEP to dependent lung
•	consider intermittent 2 lung ventilation
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95
Q

Can a left DL tube be used to ventilate the right lung

A

Yes, the RUL will be ventilated w/ the left DLT

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96
Q

What is a benefit of the bronchial blocker vs DLT

A

BBs can be placed in regular ETT
Generally size 9

Can block a segment of lung w/o isolating the entire lung to decrease atelectasis etc

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97
Q

What are indications for use of bronchial blockers

A
  • To isolate single lobes vs whole lung
  • When DLT is not advisable- use a BB!!
  • Nasal intubation
  • Difficult intubation
  • Patients with tracheostomy
  • Subglottic stenosis (cant pass DLT)
  • Need for continued postoperative intubation
  • If a single-lumen tube is already in place
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98
Q

What are some difficulties with bronch-blockeres

A

• Difficult to position on right
 if upper lobe bronchus takeoff is short
• Fixation by staples during surgery
 can occur or perforation by suture needle or instrumentation

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99
Q

What are some invasive airway techniques

A 
Retrograde intubation
Cricothyrotomy 
Quicktrach
Tracheostomy
Jet ventilation
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100
Q

When would an anesthetist resort to invasive airway techniques

A

failure to intubate and failure to ventilate

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101
Q

What is retrograde intubation

A

 technique involves making incision in the neck
 the passage of a wire through the trachea
 then up through the upper airway
 then a tracheal tube is placed over the wire

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102
Q

How is cricothyrotomy performed

A

 an incision made through the skin and cricothyroid membrane
• to establish a patent airway during certain life-threatening situations
 usually with a scalpel and tracheal tube
• or with a cric kit

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103
Q

What is the design and insertion of the qiucktrach

A

 has a beveled needle for quick tracheal access instead of a scalpel and has a built-in stopper to prevent posterior tracheal perforation
-Take needle portion out and start ventilating

Through cricothyroid membrane

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104
Q

How is a tracheostomy performed and for what purpose

A 
For prolong ventilation
	either temporary or permanent 
	involves creating an opening in cricoid cartilage**
•	to place a tube into the trachea
-Shiley cuffed or uncuffed
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105
Q

How is jet ventilation used with advanced airways

A

 an alternative, rescue technique to open tracheotomy or cricothyrotomy
• use of transtracheal ventilation
 a large-gauge catheter attached to a syringe
• used to enter the trachea
• aspiration of air from the trachea confirms placement of needle tip
• then jet ventilation can be provided

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106
Q

What is total body water composition and the 2 compartment compositions.

A

Total Body Water
• 60% of total body weight
• Table 59-1 Miller

2 compartments
• Intracellular 40%
• Extracellular 20%
•	Interstitial 15% (gel-like compartment that facilitates diffusion btwn capillary and tissue)
•	Plasma 5% (3 L)
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107
Q

What type of tissue are RBCs

A

cellular tissue

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108
Q

How does fluid exchange occur between compartments. What are different types of fluid exchange.

A

 Fluid exchange across capillary beds

Types

  • Diffusion
  • Intercellular clefts
  • facilitated diffusion
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109
Q

Describe diffusion and what molecules follow this exchange pattern.

A

Diffusion:
• Process by which solute particles fill the available solvent by movement from high concentration to low concentration

Molecules:
O2, CO2. H2O

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110
Q

Describe intercellular clefts and prominent ions that follow this exchange pattern.

A
  • Allows transportation of fluids and small solutes/matter through the endothelium i.e. allowing electrolytes to cross by facilitated diffusion??? (her words)
  • Na+, Cl-, K+
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111
Q

What is facilitated diffusion. What molecules utilize this transport method

A
  • process of spontaneous or passive transport of molecules across the membrane via a transmembrane integral protein.
  • Passive means it doesn’t directly require energy from ATP.
  • Molecules and ions still move down their concentration gradient

Molecules:
Glucose, proteins

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112
Q

What is osmosis

A
  • The movement of H2O through a semipermeable membrane that is not permeable to solutes but it is to H2O
  • H2O will diffuse into areas of higher solute concentration
  • H2O follows solutes
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113
Q

What are examples of high MW molecules. What can happen if the cross cell membranes

A

examples:
glucose, proteins

Cross membrane:
the get trapped

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114
Q

Dominant ICF and ECF cations

A

ECF=Na+

ICF=K+

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115
Q

How is fluid regulated via intake/output

A

Thirst

Urine output

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116
Q

How does thirst regulate fluid

A
  • changes in body fluid tonicity

* changes in extracellular fluid volume

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117
Q

How does urine output help regulate fluid

A
  • Antidiuretic Hormone (ADH); renal H2O excretion in response to plasma tonicity
  • Atrial Natiuretic Peptide (ANP); acts on é Na and volume with é renal Na excretion
  • Aldosterone: acts on ê Na and volume with renal Na and water conservation
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118
Q

How is ADH managed. What happens if there is too much or too little.

A

 Osmotic receptors in hypothalamus detect changes in osmotic pressure
 Regulates release of ADH
 Too little=diuresis
 Too much=retain

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119
Q

What are other factors for ADH release

A 
Stress
Nausea
Opioids
Hypoxia
Pain
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120
Q

When can ADH release begin

A

Blood volume loss of 5-10%

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121
Q

How does atrial natiuretic peptide (ANP) affect fluid regulation

A

acts on inc Na and volume with inc renal Na excretion

Na LOSS

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122
Q

How does aldosterone affect fluid regulation

A

acts on dec Na and volume with renal Na and water conservation

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123
Q

How does aldosterone affect water regulation

A

High aldosterone = fluid retention

Low aldosterone = fluid loss

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124
Q

How is H2O managed in the kidneys

A

 Delivery of tubular fluid to diluting segment of nephron
 Separation of solutes and water
 Variable reabsorption in collecting duct

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125
Q

What is the most common delivery problem in the kidneys r/t H2O management

A

Delivery of tubular fluid to the diluting segments of the nephron d/t hypotension
Leads to AKI

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126
Q

What are 6 principles of fluid management

A 
	Assess maintenance fluid requirements
	Replacement of fluid or electrolyte deficits
	Maintenance of intravascular volume
	Replacement of intraoperative losses
	Assessment of blood loss
	Blood replacement therapy
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127
Q

What type of volume change do anesthetics cause

A

Relative hypovolemia d/t widespread vasodilation causing hypotension
Fluid may have been redistributed

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128
Q

How are fluid management principles used to guide patient care and what warning should be heeded

A

Warning!!!!
 These principles form a basis for fluid management
• but the rules are subject to change w/o notice
• can be patient dependent! (renal, comorbidities etc)

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129
Q

What is a crucial part of preop pt assessment

A

 A crucial part of your pre-op assessment

 will involve evaluation of fluid and electrolyte balance!!

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130
Q

What are basic guidelines of maintenance fluid requirements

A

 Water requirement is proportional to metabolic rate

 During a 24 hour period- water in = water out

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131
Q

Where does fluid loss occur typically? Difference in sensible and insensible?**

A

Losses: skin, urinary, GI, respiratory tract
• Insensible losses (skin + resp, open abd) 25-30%**
• Sensible losses (urine + GI) 70-75%**

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132
Q

What is normal average daily intake and output

A 
She says we dont need to memorize
Intake:
	750 mL from solids
	350 mL from metabolism
	mL liquid intake

Output:
 Insensible loss 1000 mL
 GI loss 100 mL
 Urine Output 0.5-1 mL/kg/hr

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133
Q

What is traditional hourly maintenance calculation***

A

Basic Formula
• 1st 10 kg=4 mL/kg/hr
• 2nd 10 kg=2 mL/kg/hr (first 20 kg  60 ml/hr)
• Each kg > 20=1 mL/kg/hr

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134
Q

What are the NPO guidelines***

A 
	Clear liquids = 2 hr fasting period
	Breast milk = 4 hr fasting period
	Infant formula= 6 hr fasting period
	Light meal= 6 hr fasting period
	Meat, fatty foods, fried foods= 8 hr fasting period
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135
Q

What have current studies determined about NPO guidelines***

A
  • preop fasting overnight for approx 10 hrs, does not significantly reduce intravascular volume***
  • again based on patient!!
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136
Q

How can dehydration be avoided during preop fasting

A
  • by limiting the fasting period
  • the consumption of clear liquids
  • recommended up to 2 hrs prior to surgery
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137
Q

What preop conditions can cause intravascular volume loss and why

A

 bowel obstruction and pancreatitis

due to inflammation and interstitial edema

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138
Q

Calculate hourly maintenance and NPO deficit for a 178 lb male who’s NPO for 8 hrs.
Give hourly totals

A

hourly maintenance = 121 ml/hr

Deficit total = 968
1st hr = 484 (total 605)
2nd hr = 242 (total 363)
3rd hr = 242 (total 363)

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139
Q

54 minute video for fld mgmt

A

pg 14

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140
Q

What are alternatives to homologous blood therapy

A

autologous blood

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141
Q

What are benefits of autologous blood therapy. What are the 3 types

A

avoids complications of donor blood

conservation of resources

3 types:
Preop donation
Intraop hemodilutoin
Intraop recovery

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142
Q

What are the guidelines of pre-donation autologous donation

A 
• H/H 11/33
• Timing
•	72 hours apart
•	72 hours preop
Even very small children can do this
OB patients with placenta previa can do this

Still requires type and screen/crossmatch

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143
Q

What are benefits for using autologous blood

A

Pt may get transfused w/ their blood at a higher h/h than for cases w/o autologous donation (she says “lower threshold”)

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144
Q

What are some things to consider with autologous blood donations

A

50% of this blood is discarded
wrong pt-wrong unit can still happen**
Less “questioning”

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145
Q

How is platelet dysfunction avoided in autologous donation.

How does this affect the blood and pt tissues.

A
  • Temp maintained so no platelet dysfunction
  • Increased tissue perfusion due to decreased viscosity
  • Multiple studies show it decreases the need for donor transfusion
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146
Q

What is acute normovolemic hemodilution

A

When practitioner draws off blood to a hct of 28%

Provides volume expansion (3ml:1 ml crystalloid or 1:1 colloid)

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147
Q

What are storage considerations with acute normovolemic hemodilution

A
  • No storage related complications
  • Same room, no crossmatch
  • Stored at room temp for up to 8 hours
  • 8-24 hours refrigerated, then discard
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148
Q

How is acute normovolemic hemodilution performed

A
  • Blood drawn from large central vein or radial artery
  • Collected in standard blood bags containing anticoagulant
  • Stored at room temp for up to 8 hours***
  • 8-24 hours refrigerated, then discard
  • With hemodilution, CO increases and oxygen extraction increases
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149
Q

What are relative complications/contraindications to ANH

A 
•	Renal insufficiency
•	Pulmonary disease
•	Preexisting coagulopathy
•	Myocardial ischemia
•	Cerebral hypoxia
sickle cell??
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150
Q

What is the process for cell saver and another name for it

A

aka Intraop blood recovery

Suction -> anticoag reservoir -> filter and wash -> centrifuge -> waste

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151
Q

What is given back to the patient when cell saver used

A

RBC only

plt, wbc, clotting factors and debris are all washed out

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152
Q

What is the purpose of cell saver use

A

• Oxygen carrying capacity > PRBC due to fresh and has not been cooled

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153
Q

What are some differences in ANH and cell saver blood return

A

ANH = whole blood

Cell saver = RBCs only; plt, wbc, clotting factors and debris are washed-out

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154
Q

What procedures would cell saver be useful

A 
Long spine surgeries with larger blood losses
•	Cardiac
•	Vascular
•	Orthopedic (Becky??)
•	Trauma
•	Can be used in OB, need
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155
Q

What are complications to consider with the use of cell saver***

A
  • Air embolism rare and procedure dependent

* Renal dysfunction from damaged cells (usually comes from excessive suction and poor washing)

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156
Q

What are some considerations when utilizing cell saver for blood therapy

A

• Requires same platelet and FFP replacement as donor units
• Infection potential from bowel wounds b/c not all bacteria are washed out
• Tumor cells may remain in washed blood
• Must irrigate after for Thrombin use
or Cement use

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157
Q

What may not be washout from blood when using cell saver

A

Not all bacteria

Tumor cells may remain

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158
Q

What are contraindications for cell saver use??

A

???

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159
Q

What are disadvantages of cell saver use

A
  • It is expensive
  • Trained person
  • Device
  • Disposables
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160
Q

What is the golden rule for NPO defecit replacement

A

1st hour = 1/2 of deficit
2nd hour = 1/4 of deficit
3rd hour = 1/4 of deficit

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161
Q

What are preexisting deficits caused by abnormal fluid losses

A
  • Preoperative bleeding
  • Vomiting
  • Diarrhea
  • Diuresis
  • Fluid sequestration (trauma/infection)
  • Bowel prep
  • Fever
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162
Q

What are preexisting disease caused fluid loss

A
  • Ascites
  • HTN
  • DM
  • Bowel obstruction
  • Peritonitis
  • Burns
  • Shock
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163
Q

What are the burn fluid guidelines

A

• Burn fluid therapy

 2-4 mL/kg/% burn first 24 hours

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164
Q

What are the guidelines for fever and fluid deficit replacement

A

• 10C fever = ↑ fluid deficit 10%

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165
Q

What is the goal of deficit fluid replacement***

A

 The goal
 to correct fluid and electrolyte imbalance
 Timing is everything!!

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166
Q

What signs on the physical exam can indicate fluid defecit

A 
	Skin turgor
	Hydration of mucous membranes
	Peripheral pulses
	Orthostatic hypotension
	Urinary flow rate
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167
Q

At 5% deficit, what aspects of physical assessment are affected and to what degree?

A 
mucous membrane = dry
sensorium = normal
orthostatic = none
B/P = no change
Urine = mild decrease
Pulse = slight increase
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168
Q

At 10% deficit, what aspects of physical assessment are affected and to what degree?

A 
mucous membrane = Very dry 
sensorium = lethargic
orthostatic = present
B/P = no change
Urine = Decreased
Pulse = >100 bpm
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169
Q

At 15% deficit, what aspects of physical assessment are affected and to what degree?

A 
mucous membrane = parched
sensorium = obtunded
orthostatic = marked
B/P = Dec >10 mmHg
Urine = marked decrease
Pulse = 120 bpm
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170
Q

What are some assessment clues that hypervolemia is present

A 
	Pitting edema
	Presacral, pretibial edema
	Increased urinary flow
	Tachycardia
	Pulmonary crackles
	Wheezing
	Cyanosis, pink frothy resp secretions
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171
Q

What are lab value clues for hypo/hypervolemia

A 
Hypovolemia***
•	Rising Hct
•	Progressive metabolic acidosis
•	Hypernatremia
•	BUN:Cre > 10:1

Hypervolemia***
• X-ray changes
• Increased vascular and interstitial markings
• Diffuse alveolar infiltrates

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172
Q

When should fluid bolus/challenge be considered for fluid management

A

Very important in GDT

↓ intravascular volume vs ↓ CO/contractility??
CVP ↑ 1-2 mmHg 
•	volume***
if ↑ 5 mmHg 
•	Has volume load 
•	need contractility
	250-500 mL bolus
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173
Q

What are the general principles of maintenance fluid administration.

A 
	Polyionic; isotonic or hypotonic
	Generally 
	used for long term fluid maintenance (floor, ICU)
	low in NaCl
	high in K+ 
	contain glucose
	D5 ½ NS, ½ NS, D5 ¼ NS
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174
Q

What are metabolic requirement of glucose

A

4 mg/kg/hr

175
Q

What are 2 types of intraop fluid loss

A

Evaporative loss

Internal redistribution

176
Q

What are evaporative vs internal redistribution losses.

A

Both intraop fluid loss

Evaporative Losses
• directly proportional to the surface area exposed and the length of the surgery

Internal redistribution
• fluid shifts from traumatized, inflamed or infected tissues. Large amounts of fluid can be sequestered in interstitial and across serosal surfaces

177
Q

What are evaporative vs internal redistribution losses.

A

Both intraop fluid loss

Evaporative Losses
• directly proportional to the surface area exposed and the length of the surgery

Internal redistribution
• fluid shifts from traumatized, inflamed or infected tissues. Large amounts of fluid can be sequestered in interstitial and across serosal surfaces**

178
Q

Why and how do fluid shifts occur during anesthesia

A 
	Most anesthetic agents produce 
•	vasodilation 
•	relative hypotension
	Decreased SNS activity
	Reduce PVR
	Relative hypovolemia
179
Q

What are can result from relative hypovolemia

A

Decreased SNS activity
Reduce PVR

  • ~ 15% volume is arterial
  • ~ 85% volume is venous
180
Q

When is GDT typically used. What are requirements

A

Selected in patients:
• undergoing major invasive surgery
• with EBL expected > 500 mL
• and/or other significant periop fluid shifts

Requires that intravascular volume status
• is optimal prior to vasopressor therapy to achieve optimal BP

181
Q

What are some evidence based support for GDT

A

Many studies deem GDT superior to liberal and conservative fluid management

Results from one meta-analysis supported use of GDT over traditional fluid management was associated with:
•	-improved clinical outcomes
•	-decreased mortality
•	-decreased pneumonia and AKI
•	-shorter length of stay
182
Q

What are fluid administration guidelines with GDT. Maintenance fluid vs fluid loss administration.

A

Maintenance:
• 1-3 mL/kg/hr w/ crystalloid solution
 to replace losses

Min fld loss:
• treated w/ fluid challenges
• usually in 250 mL increments

Additional blood loss:
•	treated with crystalloid 
	1.5 X the amount of the blood loss 
•	colloids 
	on a 1:1 ratio
183
Q

What are monitoring guidelines for GDT. Why are they used?

A

Invasive monitoring devices (Must have)
• to provide a calculated SVV
• to assess responsiveness to fluid challenges
-Art BP w/ waveform, thoracic biomipedence, CVP, echo, labs

TEE is another option
• to visually evaluate fluid responsiveness
• quantify LV cavity size/ejection

Used to achieve pre-specified parameters
• specific to that pt and their condition/comorbidities

184
Q

In what types of cases are traditional fluid management used

A
  • minimal fluid
  • blood losses based on pt
  • case presentation
185
Q

What are the primary goals of fluid management?

A

 Replace insensible fluid losses
 Replace sensible fluid losses
 Maintain an adequate and effective blood volume
 Maintain cardiac output and tissue perfusion under anesthetic
 Maintain adequate oxygen delivery to tissues (600 mL O2/m2/min)
 Redistribution and Evaporative Losses

186
Q

What are the guidelines for redistributive and evaporative levels of losses

A

 Minimal=0-2 ml/kg/hr (2)
 Moderate=2-4 ml/kg/hr (4)
 Severe=4-8 ml/kg/hr (6)

187
Q

What replacement fluids can be used

A

 Generally polyionic isotonic fluids
 LR, Plasmalyte, NSR, NS (0.9%)
 Fluids that closely mimic plasma electrolyte concentrations

188
Q

What is the mOsm of the most commonly administered fluid during surgery

A

 273-308 mOsm/L

189
Q

What are some colloids, makeup and their benefits

A 
Colloids:
Starch, dextran or plasma proteins
	Blood derived
•	5% + 25% albumin
•	5% plasma proteins (allergenic)

Make-up
Various MW designed to remain in the intravascular space

Benefit
• maintain intravascular fluid volume

190
Q

Types of colloid fluids. Problems with colloids

A 
Types:
•	Hetastarch
•	less allergic reactions than dextran, 20 mL/kg 
•	Hespan 
•	Voluven 
Problems with Colloids
•	Allergic reactions
•	Impaired coagulation
•	Renal damage
•	More expensive than crystalloids
191
Q

What are reasons to consider colloids

A

Fluid resuscitation in patients
• with severe intravascular deficits p/t arrival of blood

Fluid resuscitation
• in the presence of severe hypoalbuminemia

192
Q

Relative reasons to consider colloids

A

Fluid administration in patients with CV disease –caution overload

Preload for regional placement in severe pregnancy induced hypertension

In conjunction with crystalloids,
• when replacement needs&raquo_space; 3-4 L
 prior to transfusion

Albumin replacement
• after paracentesis 4-8 g/ L of ascites
• protein rich fluid removed

193
Q

What are the half lives of crystalloid and colloids

A

Crystalloid intravascular ½ life
• 20-30 minutes
Colloid intravascular ½ life
• 1.5-6 hours

194
Q

How is the benefit of fluid management measured

A

Urine minimum 0.5-1 ml/kg/hr

195
Q

What is the problem using urine as a measure for fluid status

A 
	Increased ADH secretion d/t stress response
	PPV decreases VR– CO – GFR
	SNS activation of ANP
	Positioning
	Intraabdominal pressure
196
Q

What measures should be used to assess fluid management vs UO

A 
	Stroke Volume Variation
	Ultrasound
	TEE
	ABG
	DO2I 600ml O2/m2/min
197
Q 
	55 year-old male
	225 lbs
	Hypertensive
	Medications; Lipitor + Ace inhibitor
	NKDA
	Cholecystitis
	Laparoscopic cholecystectomy at 14:00 pm
	 2 hour case
	NPO since midnight

Calculate hourly maintenance and first 3 hour npo deficit replacement. Intraop mod loss and first 3 hours total…

A 
Hourly maintenance:
	225 ÷ 2.2 = 102 kg
	4 ml/kg  1st 10 =  40 mL
	2 ml/kg  2nd 10 =  20 mL
	1 ml/kg last 82 =  82 mL
	                            142 mL/hour
Deficit replacement
	142 mL X 14 hours = 1988 mL
	1st hour = 994 ml
	2nd hr = 497
	3rd hr = 497

Intraop mod loss
102 x 4 = 408 ml/hr

Total replacement
1st hour = 1544 ml
2nd hr = 1047
3rd hr = 1047

198
Q

How is allowable blood loss calculated

A

 Calculate average Blood Volume
 Estimate the RBC volume w/ the preop hematocrit
 Estimate the RBC volume at 30% assuming normovolemia
 RBCV (preop) – RBCV (30%) =RBCV lost
 Allowable blood loss = RBCV lost x 3

199
Q

What are the ml/kg for estimated blood volume

A 
Neonates
	Premature		100 mL/kg
	Neonate		90 mL/kg
Infants			80 mL/kg
Children			70 mL/kg
Adults
	Men			75 mL/kg
	Women		65 mL/kg
	Morbid Obese		60 mL/kg (> 40 BMI
200
Q

Calculate the ABL for 70 kg woman w/ HCT 38%

What is her blood volume, RBC volume and her estimated normal RBC volume?

A

1729 (est BV) – 1365 (normal BV) = 364 mL

364 x 3 = 1092 mL allowable blood loss

Blood volume = 4500 ml
RBC volume = 1729 ml
Normal RBC vol = 1365 ml

201
Q 
Mark HPI:
	Low anterior resection for colon cancer (4-hours)
	58 year-old man
	6’ , 200 lbs
	NPO since bowel prep at 9:00 pm
	7:00 am case
	Hgb. 13.4 : Hct. 40.2

What is
Maintenance rate
What is NPO deficit and first 3 hr replacement
What is ABL, total blood vol, RBC vol and Normal RBC vol
Intraop moderate loss

A

Maintenance rate
131 ml/hr

NPO deficit/replacement
	131 mL X 10 hours = 1310 mL 
	+ 2000 mL for the bowel prep = 3310 mL (total NPO deficit)
1st hr = 1655 ml
2/3rd hr = 828 ml

ABL = 2088 ml
Total blood vol = 6825
RBCs @ 40% = 2744 ml
RBCs @ 30% = 2048 ml

Intraop loss
546

Total hourly replacement
1st hr= 2332 ml
2nd/3rd hr= 1505 ml

202
Q

What is consider when calculating EBL

A 
Surgical suction canister
Fully soaked sponge (4x4) = 10 mL***
Fully soaked laparotomy pad = 100-150 mL***
Irrigation
Drapes 
Oozing
203
Q

Guidelines for blood administration

A

Few practitioners use absolute numbers for transfusion
 hgb ≥ 8 NO
 hgb ≤ 6.0 YES
 8 − 6 ?

204
Q

What is the general increase in hgb and hct for adults and peds w/ 1 unit of RBC

A

1 unit PRBCs
• ↑ hgb 1 g/dL
• ↑ hct 2-3%

Peds w/ 10 ml/kg PRBCs
• ↑ hgb by 3 g/dL
• ↑ hct by 10%

205
Q

What is blood loss replacement w/ crystalloid ratio

A

 Blood loss is replaced with crystalloids at 3:1mL

206
Q

What are different types of blood component therapy

A

Whole blood
-Colloids, clotting fators, platelets, RBCs

Packed RBCs (whole blood - plasma = RBC)

207
Q

Drawbacks to stored blood

A

Reduced O2 carying capacity

Diminishing clotting effectiveness

208
Q

When are PRBCs useful

A
  • Useful in treating anemia

* High risk of fluid overload t/f Reduced risk of fluid overload, stays intravascular

209
Q

What has a greater likelihood of causing tachycardia, anemia or hypovolemia

A

Hypovolemia

assess for hypovolemia

210
Q

What are additives to PRBCs and their purpose

A 
Contains citrate 
•	binds the Ca++ 
Phosphate 
•	as a buffer 
Dextrose 
•	for fuel
211
Q

Storage and administration guidelines for PRBCs

A 
	Reconstitute with saline
	170 mm filter
	Warm to 370
	Can be stored for 35 days, best < 14 days
	250 mL of RBCs + additives = ~300 mL
212
Q

What is the minimum UO per hour for a 225 lb man. Minimum for a 3 hr case

A

51 ml/hr

153 ml for 3 hrs

213
Q

Why is the ABL result multiplied by 3

A

Because the 3x takes into consideration whole blood volume loss vs only RBC volume loss

214
Q

What does ABL indicate

A

 The amount of blood los at which tissue isn’t receiving adequate O2
• When a pt may become symptomatic

215
Q

Why is EBL calculation smaller for obese pts

A

Greater total blood volume BUT increased adipose tissue with LESS perfusion

216
Q

What is the problem if HCT is <30% in relation to ABL

A

There is NO threshold for blood loss

May need to transfuse prior to surgery

217
Q

What acid-base disturbance can be anticipated with pts having bowel preps prior to surgery

A

metabolic acidosis (ALKALOSIS) from chloride loss

218
Q

What can excessive blood product administration do to heart rhythm and why.

Treatment

A

Can prolong QT interval d/t low Ca++ from binding with citrate from blood transfusion

Give calcium chloride (0.5 -1 gm)

219
Q

What is the difference between type and screen and type and crossmatch

A

type and screen = blood type NO blood prepared or matched

type and cross = blood type AND donor blood match and prepared

220
Q

What is universal donor

A

O neg

221
Q

What conditions would FFP be used to treat (5)

A
  • Clotting factor deficiencies
  • Reversal of warfarin
  • Correction of coagulopathy
  • Dilutional coagulopathies
  • Trauma; massive transfusion protocols
222
Q

What are transfusion guidelines for FFP with other blood products

A

• 1st give 4-6 units of packed RBCs
• Then give 1:1:1 (RBC/FFP/Platelets)
 Making whole blood

223
Q

What is the makeup of FFP and storage guidelines

A

Makeup
• Contains all plasma proteins
• Contains all clotting factors

Storage and administration requirements
•	Each unit is about 200 mL
•	Stored frozen
•	Once thawed it must be used in 24 hours
•	Better if typed but not mandatory
224
Q

When are platelets used

A

thrombocytopenia

dysfunctional platelet conditions

225
Q

What makes up a unit of platelets vs whole blood

How does 1 unit of plt affect plt counts

A
  • 1 unit of whole blood
  • 50-70 mL of platelets plus plasma
  • Each unit of platelets inc count by 5,000 to 10,000***
  • pheresis single donor units
  • produce 6 units of platelets
226
Q

Guidelines for plt levels and surgery

A

• 10,000 – 20,000 = risk of spontaneous bleeding
• < 50,000 = risk of surgical bleeding
•
100,000 is a minimum for major surgery
• Some minor procedures can be done at lower levels

227
Q

What are other types of clotting assistance

A

 Cryoprecipitate: concentrated fibrinogen, Factor VIII & Von Willebrand

 Recombinant Factor VII: activates factor X, converts prothrombin to thrombin

228
Q

What are some causes of bleeding in surgery

A

 Surgical / Trauma
 Severe Hypothermia (affects clotting cascade)
 Coagulopathy (can be affected by hemodilution)

229
Q

What are causes of hemolytic reactions to transfusions

A 
	Unknown cause 
	Nonhemolytic 
	TRALI (trxfn related acute lung infxn)
	TACO (trxfn acute circulatory overload)
	sepsis
HIV
230
Q

Awake vs asleep s/sx of hemolytic reactions

A 
awake:
•	Chills
•	Fever
•	Nausea
•	Chest pain
•	Flank pain
Asleep:
•	Tachycardia
•	Hypotension
•	Hemoglobinuria
•	Diffuse oozing
•	DIC
•	Renal failure
•	Shock
231
Q

What signs and symptoms are evident at 50%, 30% and only 5 gm of blood volume

A

50% remains
 pt conscious

30% loss
 grey, ashy with cyanotic extremities

5 gm of hgb
 cyanosis

232
Q

time = 1:00::55

fluid mgmt 2 (2nd)

A

pg 18

233
Q 
Becky HPI
	35 year-old female 
	MVC 12:00 pm
	It’s 1050 in Texas
	Rescue and transport arrives 13:00 pm
	Fracture femur, OR for IM rod.  
	Case will take 4 hours
	NKDA, no medical problems
	5’6”, 144 lbs
	NPO: full meal at 8:00 am, MVC 12:00 pm
	100/40, 120, 22, 99%, 390
	Conscious, pale: Hgb 11.5, Hct 34.5
	Surgery at 17:00 pm

Maintenance
Deficit total and 1st, 2nd and 3rd hour replacement
What is ABL, estimate total volume, estimate blood volume and normal blood volume
What is mod intraop loss
w/ EBL of 1000L. What and how much should be given

A

maintenance during surgery
126 ml/hr (febrile)
105 ml/hr (afebrile)

Deficit
TOTAL = 1029 ml
1st hr = 515 ml
2nd/3rd = 258 ml

ABL = 570 ml
Est total vol = 4225
est blood vol = 1458
normal blood vol = 1268

Intraop
260 ml

EBL 1000 (ABL = 500) so TOTAL EBL = 500ml 
crystalloid = 1500 ml
Colloid = 500 ml
234
Q

What is DO2I and the components for calculation

A

DO2I
Delivery of O2 to the tissues
ml/m2/min

components
CaO2 (O2 content)
CI (CO/BSA)
SpO2 (% == =1)
PaO2
Hgb
hgb/O2 conversoin (1.34)
O2 solubility coefficient (0.003)
235
Q

What is the DO2I equation

A
  • CaO2 = (1.34 x Hgb x SaO2) + (PaO2 x 0.003)

* DO2I = CI x CaO2 x 10

236
Q 
Calculate Becky's DO2I
•	Hgb 7.2, Hct 21.6
•	CO 7 L/min
•	BSA 1.74
•	SpO2 100%
•	PaO2 100 mmHg
Does she need blood
What is normal DO2I
A
  • CaO2 = (1.34 x 7.2 x 1) + (100 x 0.003)
  • DO2I = 4 x 10 x 10
  • DO2I = 400

Yes give blood

Normal DO2I >600 ml/m2/min

237
Q

What What may a low DO2I in an asymptomatic pt with a borderline H/H indicate

A

The pt could still be bleeding

238
Q

what does insufflation mean

A

use of CO2 to inflate an area in order to optimize surgical exposure and visualization

239
Q

Describe the process of laparoscopy vs open methods

A

laparoscopy

  • small incisions allowing for insertion of trocars with instruments on the end to perform surgery
  • requires insuflflation to create pneumoperitoneum for visualization and exposure of surgical sites

Open procedures
large incisions the open up the abdomen for direct visualization and contact

240
Q

what are some effects of insufflation

A 
	Release at onset of pneumo-peritoneum
•	catecholamines 
•	vasopressin 
	Compression of arterial vasculature
•	Hypotension	
	Decreased FRC
241
Q

At what pressure should insufflation be maintained

A

IAP = 20 mmHg

242
Q

What are the benefits of insufflation to create a pneumoperitoneum

A
  • More space for surgeon to work with trocars
  • increase visualization of structures
  • avoids being so close to heavy vasculature
243
Q

Pulmonary effects of insufflation.

alterations to compensate for Vm changes

A
  • dec compliance 30-50%
  • inc PIP
  • dec FRC
  • inc Vm 20-30%.
  • inc PaCO2
  • diaphragm elevation
  • cephalad displacement of carina causing endobronchial intubation
244
Q

What is the purpose of not ventilating > 20 cmH2O

A 
gastric distention (but if they have an ETT how is this a problem???)
	WRONG you can go above 20 w/ ETT in correct place
don't go above 40 w/ ETT
don't go above 20 w/ LMA or mask vent
245
Q

What are some lung protective strategies when abd is insufflated

A
  • pressure control ventilation
  • -can use pressure >20 cmH2O ok w/ ETT NOT LMA or mask
  • inc RR
246
Q

What causes inc PaCO2 r/t insufflation

A
  • abd distention

* CO2 gas absorption w/ plateau @10-15 min

247
Q

How does diaphragm elevation affect pulmonary status during insufflation. How should these possible effects be monitored

A

Cephalad displacement of carina
• can result in endobronchial intubation!
• Monitoring after position change and insufflation
 Monitor position of ETT
 Bilateral breath sounds
 Pulse oximetry

248
Q

What are pulmonary complications with laparoscopic insufflation

A
  • Endobronchial displacement of ETT
  • SQ emphysema d/t Placement of trocars (absorbs)
  • PTX (pressure on lungs), pneumomediastinum (pressure on heart/lungs) which usually resolves in 30-60minutes w/ dec of insufflation
  • Gas embolism
249
Q

What are hemodynamic effects of insufflation

A 
•	Decreased CO at onset of insufflation
•	Elevation of SVR and PVR
•	Arrhythmias
•	
•
250
Q

Why is CO affected by insufflation

A

b/c dec VR d/t compression on abd vena cava

251
Q

How can SVR and PR d/t insufflation be treated

A
  • Dilating anesthetics, b-blockers, remi
  • Limit insufflation pressures
  • dec tburg angle
252
Q

What may occur to cardiac rhythm during insufflation and how can this be treated

A
  • can develop cardiac arrhythmias that doesn’t correlate w/ PaCO2 level
  • give glycopyrolate
253
Q

What can lead to a gas embolism, what are s/sx and how is it treated

A

• Usually Develops typically during insufflation

S/Sx 
•	Tachycardia
•	Cardiac dysrhythmias
•	Hypotension
•	Millwheel murmur (air murmur?)
•	Hypoxemia/decreased ETCO2 
Treatment 
•	d/c gas insufflation
•	d/c N2O (expands cavity even more)
•	Release of pneumoperitoneum
•	Left lateral decubitus/Aspiration of gas
•	Supportive measure
	Absorption of CO2
254
Q

What are supportive measures for gas embolism

A

await absorption of CO2

maintain CO

255
Q

What are position effects when head up vs head down

What can lithotomy positioning lead to

A

Head up
• Decreased CO, venous stasis
• Favorable ventilation (less pressure on thoracic cavity)

Head down
•	Facial/pharyngeal/laryngeal airway edema
•	Increased CVP/CO
•	Increased intraocular pressure
•	Altered pulmonary mechanics

Lithotomy
 Peroneal nerve (foot drop)
 Compartment syndrome

256
Q

What is the benefit of Tburg position during lap procedures

A

displaces organs cephalic and allows for better exposure and visualization of organ to be operated on

257
Q

Describe nerve injury r/t laparoscopic positioning for surgery

A

can cause nerve injuries to
Brachial plexus
• Overextension of arm
 Shoulder support

Peroneal nerve (foot drop)
•	Lithotomy position
258
Q

What are advantages of laparoscopy vs laparotomy.

What does this result in

A

 More rapid recovery
 Better maintenance of hemostasis
 Less risk

results
 Decreases postop pain
 Decreases postop nausea/vomiting
 Results in less pulmonary dysfunction (but not none)

259
Q

What are surgical complications of laparoscopy

A 
	Intestinal injuries: perforations, CBD injury
	Vascular injuries
	Burns
	Infection
	Contraindicated w/ inc ICP
260
Q

What are the specific problems w/ these complications
 Intestinal injuries: perforations, CBD injury
 Vascular injuries
 Burns
 Infection

A 
Intestinal injuries: perforations, CBD injury
•	30-50% of serious complications
•	May remain undiagnosed
Vascular injuries
•	Retroperitoneal hematomas often insidious (can hold up to 6 L)
•	Great vessel injury emergent
Burns
•	15-20% of complications
•	r/t cautery via trocars
Infection
•	very small
261
Q

Why is laparoscopy contraindicated in presence of high ICP. List some conditions

A

inc ICP even more d/t inc and pressure and positioning and CO2 effects (cerebral vasodilation)

Conditions
tumor, trauma, hydrocephalus

262
Q

Anesthesia considerations for laparoscopy

A 
Preop meds 
GETA
	LMA=NO
•	May require higher vent pressures
•	This can lead to gastric distention
Controlled ventilation
	Normal ETCO2
	Volume vs RR
IVF for hemodynamic changes
	Young vs elderly
	aggressive vs conservative d/t possibly dec CO in elderly
	consider pressors or contractility aide
Narcotics
NMBD
	NO movement
263
Q

Postop considerations for laparoscopy

A

 Oxygen
 Prevention of nausea and vomiting
 Treatment of surgical pain or referred pain
—shoulder pain r/t gas irritation of diaphragm

264
Q

SCIP considerations for laparoscopy

Why are they in place

A 
	Antibiotics
--given in appropriate time frame 
	Beta blockers
--taken w/in 24 hrs of surgery
	Temperature
-- normothermic
	Time out

in place to improve surgical outcomes

265
Q

What are indications for fundoplication.

A

To increase LES pressure; for HH and GERD
Complications of GERD
 Stricture
 Respiratory problems
 Esophageal ulcerations
 Barrett’s esophagus
Failure of or unwillingness to commit to medications

266
Q

Preop considerations and rationale prior to fundoplications. Any specific meds?

A

PPI
• Decrease acid production
 block ATPase in parietal cells
• “prazoles”nexium, prevacid, protonix,prilosec

Prokinetic drugs
• Strengthen LES
 increase gastric emptying
• metoclopramide, cisapride

Documented esophageal hyperacidity

267
Q

Intraop anesthesia considerations for fundoplication

A 
Preop meds
GETA/RSI
OGT
Position
•	Supine, low lithotomy, reverse Tburg
SCIP antibiotics
Esophageal dilator (60 fr) = for strictures
268
Q

What type of induction is performed with fundoplication sx and why

A

RSI

d/t severe reflux to prevent aspiration

269
Q

What position is pt in for fundoplication and why

A

Supine, low lithotomy, reverse Tburg

• b/c reflux, better exposure for surgeon

270
Q

Indications for cholecystectomy

A
  • Symptomatic cholelithiasis (stones)

* Symptomatic cholecystitis (inflammation)

271
Q

What are preop considerations for cholecystectomy

A
  • Many emergent
  • Full stomach
  • Prokinetics
  • Bicitra
272
Q

What induction method would be useful in cholecystectomy

A

RSI b/c pmts considered to have full stomach

273
Q

Intraop considerations for anesthetist during cholecystectomy procedure

A 
GETA
OGT (keep stomach empty)
Position
•	Supine, reverse Tburg, left tilt
SCIP antibiotics
IOC
•	Sphincter of Oddi spasm- treat with Glucagon
May require ERCP for retained stones
274
Q

How is pt positioned for cholecystectomy and why

A

• Supine, reverse Tburg, left tilt

Why:
To expose gallbladder on the right

275
Q

Why is IOC performed and how.

What can it lead to

A
  • insertion of dye the bile duct to assess for stones or obstruction around gallbladder
  • b/c bile duct may need to be removed
  • -need X-ray in the room to visualize dye through ducts

Sphincter of oddi spasm (where bile duct sphincter and pancreas meet)

  • -treat w/ glucagon
  • -need X-ray in the room
276
Q

Why is an ecrp performed

A

to remove retained stones following cholecystectomy
prone case
GETA

277
Q

Indicatins for splenectomy

A
  • Normal or slightly enlarged spleen size
  • Immune thrombocytopenia
  • Lymphoma
  • Hemolytic anemia
  • Trauma
278
Q

Preop considerations for its undergoing splenectomy

A 
Immunizations (1 week)
•	Pneumococcal
•	Meningococcal
•	H influenza vaccinations 
Evaluate LLL atelectasis
•	r/t spleen location
279
Q

why is vaccination important w/ splenectomy

A

b/c pt will become immunocompromised

280
Q

Intraop considerations for splenectomy

A 
GETA
Type and screen
Xtra venous access (for blood admin)
Position
•	45 degree right lateral decubitus
•	Kidney rest, table flexed
SCIP antibiotics
Laparoscopic (may be converted to open)
281
Q

indications for bowel resections

A
  • Ulcerative colitis
  • Crohn’s disease
  • Diverticular disease
  • Cancers
282
Q

Preop considerations for bowel resections

A

Bowel prep
Mu-opioid antagonists
• Entereg (alvimopan)
—-may need to give to resume gut stimulation (prevents slow gut)
ERAS
• Preop warming (large temp loss w/ open and)
• Gabapentin, acetaminophen, scopolamine
• Gatorade (electrolyte replacement d/t bowel prep)
Laparoscopic may convert to open

283
Q

Intraop considerations for bowel resections

A 
GETA/RSI
•	Consider full stomach/aspiration risk
OG vs. NGT
Position
Supine or low lithotomy
SCIP antibiotics
Consider albumin vs crystalloid (d/t large old losses)
Postop pain control
284
Q

What induction method is used for bowel resection

A

RSI and GETA

285
Q

Appendectomy indications and preop considerations

A

Suspected appendicitis or rupture (s/s?)
Consider full stomach
May be dehydrated d/t fever/N&V
• Hemoconcentration

286
Q

Intraop considerations for appy

A 
GETA/RSI?
•	Consider full stomach/aspiration risk
OGT
Position 
•	Supine, left arm tucked; trendelenburg
SCIP antibiotics 
Laparoscopic (can convert to open esp for rupture)
287
Q

S/sx of appendicitis or rupture

A 
ruq pain?? (rlq??)
rebound tenderness
n/v 
dehydration
hemoconcentration
inc BUN
288
Q

What surgical method may be used w/ appy

A

laparoscopic

open if ruptured

289
Q

What induction method may be used w/ appy

A

RSI d/t full stomach

290
Q

Indications for bariatric surgery

A 
Morbid obesity associated with
BMI > 35 
•	with associated comorbidities
•	HTN
•	DM
•	OSA
•	Asthma
BMI > 40
291
Q

Preoperative concerns prior to bariatric surgery

A 
Review medication list
•	appetite suppressors?
	Alters metabolism
	dehydration? poor nutrition?
Assess airway
•	limit preoperative sedation?
	To prevent excessive erespiratory depression 
Commonly have undiagnosed OSA
VTE prophylaxis!!!
292
Q

Intraop anesthesia considerations for bariatric surgery

A

Reverse Tburg
• GOOD oxygenation
• May need to be in Tburg, or tilt to Left depending on type of bariatric sx

RSI
•	obese patients do NOT tolerate supine position
•	observe ETCO2 prior to induction
	to know baseline
	don't forget dec FRC

Induction based on end-point….

Alternate and emergent airway modalities

OGT
• removed before stomach stapled

Calibration tube/methylene blue (another type of gastric tube)

NMBD

ABX

293
Q

What type of induction is best for bariatric sx pts and why. What should be monitored

A

RSI b/c:

  • they don’t tolerate supine
  • dec FRC
  • desat quickly and difficult to return w/ mask vent
  • -can’t tolerate dynamic defat
  • Consider full stomach and risk of aspiration

monitor
-ETCO2 before starting for baseline

294
Q

What are some long-term concerns following bariatric sx

A 
Diarrhea
Dysphagia
Protein malabsorption
•	Less contact time
•	less bile/pancreatic enzymes
Vitamin malabsorption
•	A,D,E,K,B12,calcium
295
Q

Advantages and disadvantages of robotics surgery

A

Disadvantages:

  • takes a long time to remove
  • -think emergent situations like arrest
  • takes longer to perform procedure
  • more costly

advantages:

  • Shorter postop time and better outcomes
  • decreased pain and better mobility
  • improved dexterity
  • 3 dimensional dexterity
  • less intraop fluid loss??
296
Q

Intraop considerations during robotic cases

A 
General anesthesia
NMBD
•	Positioning and staying there!!!
•	Good muscle relaxation
SCIP antibiotics
•	Fluid restriction!!!
297
Q

Indications for conversion to laparotomy

A
  • Obesity
  • Adhesions
  • Bleeding
  • Unclear anatomy
  • Staple misfire
  • Inability to ventilate
  • inability to insufflate
298
Q

Indications for Ex-Lap

A
  • Trauma
  • Abdominal catastrophes
  • Staging (cancer spread and tissue samples)
299
Q

Intraop considerations for Ex-Lap

A
  • GETA
  • Profound muscle relaxation
  • NGT
  • Consider epidural placement
  • Consider multi-modal pain control
300
Q

What are concerns considered when converting to laparotomy

A
  • -increase intraop fluid loss

- -increase OR time

301
Q 
Betty HPI:
66 yo
91 kg
bowel resection for diverticuli
GETA
Start at 0700 = 4.5 hrs
Mod loss
NPO 12.5 hrs
Bowel prep
D51/2NS 1000 ml since admission
h/h = 11.2/38.6
What is maintenance rate
NPO deficit and 1st/2nd/3rd replacement
ABL, total whole blood vol, eat RBC vol, normal RBC vol
Intraop loss replacement
Total hourly replacement

Total for 3rd hr EBL 500 w/ crystalloid, colloid or blood replacement

A

maintenance during surgery
131 ml/hr

Deficit
TOTAL = 2638
1st hr = 1319 ml
2nd/3rd = 660 ml

ABL = 1526 ml
Est total vol = 5915 ml
est blood vol = 2283.19 ml
normal blood vol =1774.5 ml

Intraop replacement
364 ml/hr

Total replacement
1st hr = 1814 ml
2nd hr = 1155 ml

3rd hr = 2655 ml (w/ 1500 ml crystalloid)
= 1655 ml (500 colloid)
= 1405 (250 blood)

302
Q

Pt w/ h/h = 11.2/38.6, ABL of 1526 ml, and an EBL of 500 ml, how would you replace this and with how much?

A

crystalloid = 1500 ml

colloid = 500 ml

303
Q

What should total urine for 91 kg pt in 4.5 hr case be

A

205 - 410 ml total

304
Q 
Calculate DO2I for pt w/ the following values
h/h = 9.1/32.4
SaO2 = 100%
BSA = 1.98
CO 8 l/min
PaO2 92 mmHg

Does pt need blood based on this

A

(1. 34 x 9.1 x 1) + (92 x 0.003) = 12.47
12. 47 x 10 x (8/1.98) = 502 ml/m2/min

No need for blood
DO2I > 600

305
Q

Purpose of insuflflation in gyn surgeries

A

Intraperitoneal insufflation of CO2 intraop
IAP  = to 20 mm Hg
Identification of intraperitoneal space
• open versus closed
Physiologic changes associated with pneumoperitoneum

306
Q

Ventilatory changes due to insufflation during gyn surgeries

A 
	Decreases compliance by 30-50%
	Decreases FRC
	Increases airway pressure 
	Increases PaCO2
	Supports the development of atelectasis
307
Q

Ventilatory complications due to insufflation during gyn surgery

A

 SQ emphysema (trocar placement)
 Pneumothorax, pneumomediastinum
 Endobronchial intubation
 Gas embolism

308
Q

CV changes due to insufflation during gyn surgeries

A 
Decreased CO at onset of insufflation
Increased SVR and PVR due to compression of arterial beds
Treatment includes 
•	dilating anesthetics
•	beta blockers
•	remifentanil
•	vasodilators
•	limit insufflation pressures
Adequate fluid maintenance/replacement
cardiac arrhythmias
309
Q

When can arrhythmias occur with insufflation

A

when insufflating too fast with too high pressure

310
Q

how does position affect pt during gyn surgeries. What are typical positions for gyn sx.

A

 Physiologic changes r/t positioning (affects FRC)
 At Risk for
• CV and resp changes
• nerve injury

 Typically lithotomy
• with trendelenburg/steep trendelenburg

311
Q

Complications from gyn laparoscopic sx

A 
Intestinal injuries 
•	perforation, CBD injuries
Vascular injuries
Burns 
Infection
Contraindicated with increased ICP
312
Q

What are risk factors for postop n/v following gyn procedures

A
  • Female
  • laparoscopy < laparotomy
  • opioids
  • volatile anesthetics
313
Q

Indications for d and c

A

Removes part or entire endometrial lining of the uterus
Diagnoses and treats bleeding from uterus or cervix
• Patient groups variable (young to elderly)
Retained products of conception (RPOC)

314
Q

What can occur as a result of retained products of conception

A

increase risk for sepsis and blood loss

315
Q

Anesthesia considerations for DandC

A 
Lithotomy position
•	risk of nerve injury and table
General anesthesia vs SAB
•	Use either ETT or LMA
No SCIP abx (already "dirty" b/c van entry)
May be combined with other procedures 
May need IV Pitocin
•	Can help dec bleeding 
•	Firms uterus
Potential for bradycardia
Postoperative pain
316
Q

What is DandE

Anesthesia considerations

A

Dilation and evacuation
Generally for abortion
Performed by surgeon
usually 20-24 wks gestation

Anesthesia
similar to DandC except may be more likely to use Pitocin

317
Q

MOA for Pitocin and typical dose

A

Secreted from the neuro-hypophysis
Stimulates uterine contraction (to decrease bleeding)
Similar to vasopressin
• increases H2O reabsorption from glomerular filtrate
Typical dose is 20 units/liter (min 500 ml)

318
Q

Indications for hysteroscopy and description of how procedure is performed

A 
Allows examination of endometrial cavity
Investigates intrauterine bleeding via scope through vagina
Inflate uterus with NS, LR, or sorbitol
•	In must = out 
•	Fluid choice considerations
319
Q

Anesthesia considerations for hysteroscopy

A 
•	Lithotomy position
•	General anesthesia vs Regional
---ETT or LMA
---Paracervical block? (surgeon)
•	Local anesthetic injected along vaginal portion of cervix 
•	SCIP antibiotic 
•	Potential for bradycardia
•	Postoperative pain
320
Q

Considerations when sorbitol is used to inflate uterus during hysteroscopy

A

Possible osmotic issues

321
Q

What is a paracervical block, when can it be used

A

During hysteroscopy (other procedures??)

322
Q

Why are abx needed for hysteroscopy

A

b/c of fluid used to inflate uterus

323
Q

Why is bradycardia a possibility w/ gyn surgeries

A

Vagal response d/t stretching of abd nerves (celiac reflex?)

324
Q

Indications for urethral sling

What is used to secure sling

A
  • Loss of support to bladder neck and pelvic floor

* Can use tape, animal muscle, ligament, tendon, prolene mesh

325
Q

What can loss of support to bladder neck and pelvic floor lead to in women.
Who’s at risk and why

A

Can cause stress urinary incontinence (SUI)
 Occurs in 15-60% of women, usually older, multiparous women
 But can occur in 25% of nulliparous college athletes
—-d/t excessive strenuous repetitive exercise

326
Q

Anesthesia considerations for urethral string

A 
Lithotomy position
Enter through vag
General anesthesia 
•	usually LMA
SCIP antibiotic
Postoperative pain (cramping)
327
Q

Indications and purpose of cervical ionization and how performed

A

Procedure purpose:
• Performed for diagnosis and treatment of cervical lesions/abnormal cells

How:
• Cold knife cone (CKC-cryo)
• loop electrosurgical excision procedure (LEEP)
- excises cone shaped sample of cervix

328
Q

Anesthetic considerations for cervical conization

A

Lithotomy position
Pregnancy test
• 10-15% loss in 1st trimester if pregnant
General vs sedation vs regional anesthesia
No SCIP antibiotic
Postoperative pain

329
Q

What should be considered before blood administration as part of fluid management

A

When to give blood slide

  • organ ischemia?
  • ongoing bleeding
  • VSS? or not
  • What is cardiopulmonary reserve
330
Q

What are varying methods for hysterectomy

A

• Abdominal (Pfannenstiel or midline incision)
• vaginal
• laparoscopic assisted vaginal hysterectomy (LAVH)
 May do these with robotic techniques

331
Q

Intraop considerations for hysterectomy

A
  • -May have had bowel prep
  • -potential for bradycardia
  • -position = lithotomy or TBurg
  • -General vs SAB vs epidural
  • -SCIP Abx
  • -Foley (keep bladder empty)
332
Q

Gyn conditions that require gynecologic repair procedures

A

 Cystocele- anterior prolapse (bladder)
 Rectocele- posterior prolapse (rectum)
 Enterocele- descension of small intestine

333
Q

Why are gynecologic repair procedures performed

A

b/c pt has weakened pelvic floor d/t aging, deliveries or previous pelvic surgeries

334
Q

Anesthesia considerations for gyn repair procedures

A 
	Lithotomy position
	General anesthesia
	SCIP antibiotic
	Postoperative pain
	Foley catheter (keep bladder empty)
335
Q

Purpose of gyn cancer procedures

A

Procedures may be progressive with
 washings and biopsies of pelvis/affected areas
 removal of affected organ

Biopsies of 
	Bladder
	Gutters
	cul-de-sac
	bowel
	abdominal wall
	periaortic sites

 Pelvic exenteration–radical excision of pelvic organs w/ colostomy or urinary diversion

336
Q

Considerations for anesthesia during gyn cancer procedures

A 
Position=Possible lithotomy and trendelenburg
General anesthesia (unless van approach?)
Age appropriate preoperative assessment
•	may have had bowel prep
SCIP antibiotics
Postoperative pain
Muscle relaxation may be critical
•	NMBD
Ascites common preop (preop paracentesis)
•	intravascular volume
•	strict I and O
Potential for 
•	large blood loss 
•	ureteral stent placement
337
Q

What are genital condylomas

A 
Raised wart-like growths 
•	from viral transmission through types of HPV 
Usually painless
•	can be uncomfortable 
•	may cause itching and bleeding
Can affect both genders
338
Q

Considerations for anesthesia for genital condyloma procedures

A 
Lithotomy position
General anesthesia (LMA)
Laser evacuation procedures 
•	include smoke evacuation 
•	designated particulate masks 
	to avoid transmission- REQUIRED!
No SCIP antibiotics
Postoperative pain
339
Q

Considerations for anesthesia during gyn robotic surgeries

A 
Positioning and you are STAYING THERE!
General anesthesia
SCIP antibiotics
Adequate muscle relaxation
•	NMBD use
Fluid monitoring
•	restriction to avoid overload
•	b/c extensive OR time
Edema
•	r/t positioning and fld status
•	May require prolong emergence to assess airway readiness
340
Q

Abdominal region of GU system innervation

A

• ANS via SNS and PSNS path

341
Q

Pelvic region and genitalia innervation

A

• somatic and autonomic nerves

342
Q

Kidney and ureter pain innervation.

Why is this important w/ regional techniques

A

referred via
•somatic distribution of T10 – l2

Regional importance
effective neural block is essential for T10-12

343
Q

Bladder sensation/stretch/fullness vs pain/touch/temp innervation

A

Sensations of stretch and fullness
• PSNS innervation,

pain, touch and temperature
• supplied by SNS

344
Q

In the bladder, what does the PSNS vs SNS innervate

A

PSNS
sensation/stretch/fullness

SNS
pain/touch/temp

345
Q

Innervation of bladder base/urethra vs dome/lateral wall

A

Bladder base and urethra
• mainly alpha adrenergic

Bladder dome and lateral wall
• mainly beta adrenergic

346
Q

In the bladder, what areas are innervated by alpha adrenergic vs beta adrenergic nerves

A

alpha
–bladder base and urethra

beta
–bladder dome and lateral wall

347
Q

Prostate and prostatic urethra innervation and origin

A

SNS and PSNS
• from prostatic plexus
• spinal origin is lumbosacral

348
Q

 Penile urethra and tissue innervation

A

• ANS from the prostatic plexus

349
Q

Scrotum innervation

A
  • anteriorly = ilioinguinal and genitofemoral nerves

* posteriorly = perineal branches of the pudendal nerve

350
Q

Teste innervation. Important considerations for regional technique

A 
similar nerve supply to kidney and upper ureter 
extending to T10
•	Important for regional nerve block
	For pain control
	To blunt surgical stimuli
351
Q

Anesthesia considerations for renal and GU surgeries

A 
Extremes of age
Cardiac and respiratory comorbidities 
Detailed 
	history, physical 
	lab tests 
•	BUN, CREATININE CLEARANCE, GFR, URINALYSIS, electrolytes, 
	Review any Preop testing
•	ekg, ct scan, mri
HPI
	ESTIMATION OF DISEASE DURATION 
	TREATMENT/DIALYSIS/TRANSPLANT
Procedures location/organ involvement
Sensory innervation
Periop AKI
352
Q

Why is sensory innervation consideration important for GU surgery

A

innervation mainly thoracolumbar and sacral
regional anesthesia is common
• combination technique w/ GETA
• Very common

353
Q

What does periop AKI depend on w/ GU surgeries

A 
type of surgery 
preop kidney function
treatment 
•	medications
•	possible dialysis
354
Q

Renal CV considerations intraop

A 
15-25% of CO
Majority of bf to renal cortex
•	5% to renal medulla 
•	renal papillae susceptible to injury
•	inc renal VR
•	dec renal BF
•	dec CO from anesthetics
Prolong dec in art pressure and BF
•	dec GFR
•	compounds potential for intraop AKI esp if autoreg is lost d/t prior injury or disease
355
Q

How does SNS stimulation during surgery affect renal vasculature

A
  • can increase RenalVR
  • decrease renal bf
  • on top of anesthetic effect of decreased CO
356
Q

What can happen to kidneys w/ prolong hypotension and dec BF

A

• will decrease glomerular filtration rate (GFR)
 if autoregulation is lost d/t INJURY OR DISEASE
 more likely to have kidney injury intraop

357
Q

Important renal consideration for its w/ autoregulation probs d/t prior injury or disease

A

decrease GFR

 more likely to have kidney injury intraop

358
Q

What is GFR and why is it important

A
  • BEST MEASURE OF GLOMERULAR FUNCTION

* APPROX 125 ML/MIN

359
Q

When is reduced GFR manifested

Renal issues at 30% dec GFR and 5-10% normal GFR

A

MANIFESTATIONS OF REDUCED GFR
 NOT SEEN UNTIL &laquo_space;50% OF NORMAL

30 % DECREASED GFR from NORMAL
 INDICATIVE OF MODERATE RI (RENAL INSUFFICIENCY)
 SEVERE RI IF DECLINE CONTINUES

5-10% OF NORMAL (or should this be 5-10% fxn left???)
 INDICATES ESRD
 REQUIRES DIALYSIS/TRANSPLANT

360
Q

how does BUN relates to renal function and GFR

A
  • NOT A direct MEASURE OF GFR
  • can be INFLUENCED BY NONRENAL VARIABLES
  • ELEVATION DOES NOT OCCUR UNTIL GFR IS REDUCED TO ~75% OF NORMAL
361
Q

how does crt clearance r/t renal function and gfr

A

• valuable b/c used as an estimate of gfr

 direct relationship

362
Q

Important considerations for pts w/ chronic renal failure

A 
hypervolemia
acidosis
hyperkalemia
cardiac/resp complicatoins
anemia 
Does the pt make urine (foley)
serial labs to assess fxn
363
Q

Why is hypervolemia an important consideration for CRF pts

A

b/c they can’t filter properly, retain fluid, and won’t respond well to large amounts of fld

364
Q

What effects does acidosis have on the CRF pt

How addressed

A

CRF can be corrected with dialysis
moderate RF pt can usually compensate
 can become acidotic and hyperkalemic postop

365
Q

Hyperkalemia considerations for pts w/ CRF, and moderate renal failure
Why does it happen

A 
impaired k+ handling in the tubules 
-can be exacerbated by other factors 
	hemorrhage
	metabolic acidosis
	medications
366
Q

What are cardiac and respiratory complications to consider for CRF pts and why

A

Htn
pulmonary congestion and edema
 r/t intraop fld overload

367
Q

What causes anemia in CRF pts, why is this important to consider and possible treatments.
Contributions to abnormal bleeding

A

d/t lack of erythropoietin production
 treatment
 iron
 erythropoietin

abnormal bleeding times and coagulopathies 
	Treatment 
	Desmopressin
	Cryo
	rbcs 
	conjugated estrogens
368
Q

How can an AKI be determined in a CRF pt that doesn’t make urine

A

assess labds

bun/crt etc

369
Q

Medications used for CRF pts periop

A 
opioids
inhaled anesthetics
propofol
succs (assess K+)
Nondepol NMB (cisatracurium is renal protective??)
Cholinesterase inhib (can reverse)
antihypertensive
pressors
370
Q

Indications and method for performing TURP

A

Indications
• Nodules begin to develop in the 40’s
• most commonly performed for bph

Method
• Resection of prostatic tissue
• metal loop
• laser

371
Q

Risks when having TURP

A
  • Bleeding
  • Dvt
  • bladder perforation
  • mi/stroke
  • renal failure
  • infection
  • complications from absorption of irrigant
372
Q

Considerations when inc bleeding occurs w/ TURP

A 
if uncontrolled bleeding
•	Terminate TURP 1st 
•	give blood products as needed 
•	foley with traction inserted
---- to tamponade bleeding
373
Q

What can extensive resection or capsular compromise lead to

A

• can increase bleeding

374
Q

Considerations for EBL r/t TURP. Why

A

• difficult to measure
• often inaccurate
—-d/t constant irrigation

375
Q

advantages of laser TURP

A 
has decreased complication r/t
	blood loss 
	irrigant
Improved outcomes
Less time

BUT
can still cause urinary tract or bladder perf

376
Q

Method of laser TURP

A

laparoscopic or robotic

position = lithotomy and steep TBurg

377
Q

What is the purpose of irrigation for TURP

What is the ideal solution

A

Purpose of irrigant
• Improve visualization

Ideal irrigant solutions 
•	Isotonic
•	electrically inert
•	nontoxic
•	transparent
•	inexpensive
•	does not exist!
378
Q

Most commonly used irrigant and administration considerations

A

moderately hypotonic-
 glycine, mannitol, and Cytal

Should be warmed
• help prevent hypothermia

379
Q

Considerations w/ glycerine use in TURP

A

Glycine solutes can cause
 myocardial depression
 CNS
 retinotoxic side effects

380
Q

Irrigant common to bipolar and laser TURP

A

techniques with NS

 helps minimize irrigant complications

381
Q

How are complications minimized r/t irrigant when performing laser TURP

A

decreased time of surgery leads to increased use of irrigant

382
Q

Prostate vascular considerations when performing TURP r/t irrigant absorption

what is absorption dependent on

A

Prostatic capsule is preserved
–to prevent irrigant being absorbed into vascular circulation
 gland has large venous sinuses
 irrigating solution is absorbed

The amount of absorption depends on
 height of irrigant
 gravity determines flow rate
 time of resection

383
Q

Complications r/t irrigant use w/ TURP

A

Excessive reabsorption
Overhydration
TURP syndrome

384
Q

What can excessive reabsorption lead to

Why is over hydration a concern

A 
Excessive reabsorption can lead to 
	pulmonary edema
	hyponatremia
	visual disturbances
	CNS and cardiovascular complications

Overhydration issue under normal conditions,
 Normal conitions
• 20-30% of crystalloid load remains intravascular
• remainder moves into interstitial spaces/redistribution

385
Q

What causes TURP syndrome, presentation and treatment.

Complications of identification in awake vs asleep pt

A

Describes complications from
• excessive irrigant resorption

Presentation 
•	Hypervolemia
•	Hyponatremia
•	Restlessness
•	anxiety (CNS)

Treatment
• fluid restriction
• diuretics
• possible na+ replacement

How can restlessness and anxiety be assessed if pt asleep

386
Q

Anesthetic technique possibilities for TURP

A

Spinal
GETA
Regional

387
Q

Considerations for anesthetic technique is dependent upon

A 
Prostate:
	Size
	Vascularity (big = more)
	duration of surgery
	presence of inflammation or infection
388
Q

Advantages of spinal in TURP

A

allows for
-ease of insertion

  • adequate relaxation
  • –pelvic floor and perineum for surgery
  • patient awake to assess mental status
  • –early recognition of complications
  • -such as bladder perforation
389
Q

When would GETA be used in TURP sx

A

 patients who need respiratory or hemodynamic support

 contraindication to regional

390
Q

Advantages of regional in TURP sx

A

-can prevent myocardial depression with inhaled anesthetics
-produces sympathetic block (prevents stress response to surgery)
-mitigates fluid overload
-decrease the incidence of
• dvt
• blood loss

391
Q

What anesthesia techniques can be combined for TURP

A

GETA and regional

GETA and spinal

392
Q

How does regional use in TURP help mitigate fluid overload

A

helps keeps fluid in vasculature

393
Q

Common positioning for TURP and common nerve injuries

A

lithotomy
slight to steep TBurg

Nerve injuries
 common peroneal
 sciatic,
 femoral

394
Q

Mortality rates s/p TURP

A 
	similar between regional w/ sedation and geta
	When differences are evident 
	longer cases
	larger glands
	increased age in favor of regional
395
Q

Indications and risks for lithotripsy

A

Indications
 used for ureteral stones low in the ureter

Risk
 ureteral damage/perforation
 keep well hydrated
 hematuria expected postop

396
Q

Anesthetic technique used w/ lithotripsy

A

geta with paralysis
 typically used
 to avoid movement,

regional used
 level should be t8-t10

397
Q

Indications and risk(5) with extracorporeal shock wave litho

A

Indications
 for urinary stones in the kidney and upper part of bladder

Risks 
	flank ecchymoses and hematoma
	damage to lung tissue
	shock wave induced cardiac arrhythmias
	keep well hydrated
•	help pass smaller stone
	hematuria expected postop
•	May have foley or irrgation
398
Q

Anesthetic techniques used w/ ESWL

A

GETA w/ paralysis
• to avoid movement,
Regional use
Flank infiltration with local with tIVA

399
Q

What else may surgeon incorporate when performing lithotripsy

A 
Cystoscopy
	Concern w/ ureter/bladder perf
stone manipulation
stent placement 
	To maintain UO
may affect anesthetic choice
400
Q

contraindications for lithotripsy

A

 Pregnancy

 untreated bleeding disorders

401
Q

Types of radical GU surgeries and method used to perform

A

Types
• Radical nephrectomy
• radical cystectomy
• radical retropubic prostatectomy

Methods
• laparoscopic
• robotic
• depending on best outcome for patient

402
Q

General intraop considerations for radical GU sx

A 
long procedures 
with large blood loss 
potential for decreased renal function
•	also CO2 insufflation 
	increase risk of increased intrathoracic CO2 accumulation
	treat inc ventilation
403
Q

Most common GU malignancy and associated procedure

A

• Most common malignancy of kidney is renal cell carcinoma
• Treatment
 radical nephrectomy
 partial nephrectomy

404
Q

Commonly used anesthetic technique for radical GU surgery

A

Geta preferred
Regional
 especially for postop pain management

405
Q

Common injuries r/t position during radical GU sx

A
  • Common injuries

* cervical plexus, brachial plexus, common peroneal

406
Q

Radical nephrectomy positioning and risks

A

flank/lateral position
 risk of dependent atelectasis

kidney rest 
	helps w/ exposure
	can decreased bp 
	compress the vena cava 
	reducing venous return
407
Q

RCC tumor complications

A

5-10% of pts w/ RCC tumor
 extends into the renal vein
 the inferior vena cava
 right atrium (more common in right side RCC)

408
Q

Risk associated with radical nephrectomy for RCC tumor

A

 circulatory failure
• from complete VC occlusion
 PE
 cardiopulmonary bypass possible

409
Q

Indications and possible structures removed w/ radical prostatectomy

A

Indications= for localized prostate cancer

Removal of 
	Prostate
	ejaculatory ducts
	seminal vesicles
	part of bladder neck 
	pelvic lymph nodes
410
Q

Risks and anesthetic technique for radical prostatectomy

A

Risks w/ open radical prostatectomy
 hemorrhage
 massive blood loss

Anesthetic technique
 GETA
 Regional
 especially for postop pain management

411
Q

Pt position when performing robotic radical prostatectomy and associated risk

A 
lithotomy, steep Trendelenburg 
	increased risk of 
•	nerve damage 
•	pneumoperitoneum
•	Risk of CO2 absorption
412
Q

What are risks of steep TBurg

A 
decreased perfusion to
•	extremities
•	vital organs
increased 
•	intracranial arterial pressure
•	icp
•	intraocular pressure
Chemosis
•	r/t degree of expected laryngeal edema 
respiratory complications 
•	including vq mismatch 
•	pulmonary congestion
venous air embolism
aspiration
413
Q

Anesthetic technique used for robotic radical prostatectomy and why

A

GETA/Muscle relaxation

To prevent visceral or vascular injury during robotic procedures

414
Q

Urogenital pain syndromes can be a result of (5)

A
  • Infection
  • anatomic anomaly
  • obstructive uropathy
  • nerve compression/damage
  • malignancy
415
Q

Concerns with benign renal tumors and treatment

A 
usually presents with flank pain
can affect renal function
potential for 
•	rupture 
•	hematoma formation

Treatment
• Symptomatic
• tylenol/neuromodulatory agents

416
Q

Renal cell carcinoma classic triad, pain presentation and treatment

A

classic triad
• hematuria
• flank pain
• renal mass

pain can indicate metastatis
• poor prognosis

treatment can include
• intercostal nerve blocks
• intrathecal opioids
• neurolysis

417
Q

Types of infectious renal disease and treatment

A

pyelonephritis and perinephric abscess
• presents with fever
• assess inflammation of surrounding organs/infection

treatment
• antibiotics
• Or surgery

418
Q

What is pseudo renal pain syndrome and treatment

A

from compression, damage, or entrapment
• of nerves of urinary system

treatment
• nerve blocks
• anti-neuropathic drugs

419
Q

What is polycystic kidney disease, causes(6) and treatment(4)

A

inherited autosomal dominant disease

causes 
	kidney enlargement 
	decreased renal function
	can cause pain
	cystic bleeding
	rupture, 
	infection
treatment 
•	renal cyst drainage
•	opioids
•	antibiotics
•	Surgery—partial nephrectomy
420
Q

What is interstitial cystitis, presentation, and treatment

A

painful bladder syndrome

presentation
• chronic suprapubic pain
• urinary changes

treatment 
•focuses on pain relief modalities 
	meds
	nerve stimulators
•possible surgery
•Abx
421
Q

What are urothelial tumors, presentation and treatment

A

most commontransitional cell carcinoma of the bladder

Presentation
• painless hematuria
• possible bladder irritability

treatment
•surgery
•pain management
 Nsaids, tylenol, opioids

422
Q

What is most common prostate cancer, presentation and treatmetn

A

most common  adenocarcinoma of prostate

Presentation
• No pain
• lumbar and sacral pain
 maybe a sign of mets to bone

treatment
• brachytherapy with seeding
• surgery
• intrathecal opioids

423
Q

Cause of prostatitis and treatment

A

Cause
• inflammation
• usually from infection
• can be chronic

treatment 
•	antibiotics
•	antiandrogens
•	NSAIDs
•	pelvic floor physiotherapy
424
Q

Testicular pain causes and treatment

A 
Causes
•	trauma
•	torsion
•	infection
•	tumor
	tumors are usually painless

treatment
• surgery
• pain relief modalities

425
Q

What is priapism and the treatment

A
  • prolonged erection over 4 hrs
  • ischemic (medical emergency) vs nonischemic

treatment
• penile nerve block
• followed by blood aspiration
 for ischemic priapism

426
Q

What is Peyronie’s disease and treatment

A

severe penile pain with intercourse
• due to curvature

treatment
• surgery
• NSAIDs

427
Q

What is vulvodynia and treatment

A
  • chronic pain due to
  • sexual inactivity
  • dysfunction causing vulvar pain
treatment 
•	tricyclic antidepressants
•	sitz baths
•	estrogen creams, 
•	pudendal nerve blocks
428
Q

What is dyspareunia, possible causes and treatment

A
  • persistent genital pain
  • before or after intercourse
Causes?
	trauma
	lubrication
	vaginismus 
	increased pelvic muscle tone causing spasms
	infection
	may be psychological;

treatment
• desensitization
• pelvic floor physiotherapy

429
Q

What can lead to chronic pelvic pain and treatment

A 
Causes
•	dysmenorrhea
•	endometriosis
•	pelvic congestion
•	adhesions or pid
•	cancer of the cervix or uterus; 
treatment 
•	correction of underlying disorder 
	may include surgery, if cancer 
	aggressive opioids 
	intrathecal or neurolysis interventions 
	superior hypogastric plexus block
430
Q

List conditions that can lead to GU pain syndromes (15)

A
  • Benign renal tumor
  • Renal cell carcinoma
  • infectious renal disease
  • Pseudorenal pain syndromes
  • Polycystic kidney disease
  • interstitial cystitis
  • Urothelial tumors
  • Prostate cancer
  • Prostatitis
  • Testicular pain
  • Priapism
  • Peyronie’s disease
  • Vulvodynia
  • Dyspareunia
  • chronic pelvic pain
431
Q

What is the principle behind ultrasound

A

the idea of “seeing” using sound waves

432
Q

Historical uses of ultrasound

A

1974 Spallanzani discovered Bats used US

Used by military

1950s began use In medicine
-mostly obstetric

433
Q

Advantages of US

A
  • ID anatomic structures (especially deep)
  • inc accuracy of access etc
  • May decrease time
  • may decrease complications
434
Q

Principles of US wave travel and reflection

A

Travel 2-20 Mhz
 Travels differently in different structures
(Audible sound = 20-20,000 Hz)
When sound waves interface (encounter a surface)
 Transmitted
 Reflected
 Something in between
Sound waves are reflected back to crystals
 create impulse recorded by the computer

Principles of Anesthesia I (4 decks)

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