E3 Flashcards
When would an esophageal obturator/combitube be used
Failure to intubate
• introduced as a sub for intubation
• esp by EMT/paramedics
What is a combitube and the functions of it’s parts.
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
Types of manufactured rigid DLs
- single piece
* detachable blade/handle
What are the components of a rigid DL
Light source
Handle
Blade
Describe the light source for the laryngoscope
• light bulb or fiberoptic
What is the design of the laryngoscope handle? How is it held?
- 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)
What is the laryngoscope blade purpose and it’s design.
- inserted into mouth
- different sizes
- increasing number=increased size
- tongue=manipulate and compresses soft tissue for better insertion
- directly or indirectly elevates epiglottis
Design and sizing of macintosh blade
• Tongue has gentle curve
anatomical- Tip is in and visualize vallecula
b/c epiglottis is pulled forward
Size:
• #3 and #4 = useful for adults
advantage and disadvantage of the macintosh blade
advantage
• Makes intubation easier
b/c blade requires mouth opening due to blade size
Disadvantage
• Can cause greater c-spine movement than with Miller
When a macintosh blade is used, how is it inserted and what is visualized
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
Design and sizing of the miller blade
Tongue is straight
with slight upward tip-
Blade goes over epiglottis and lifts it
Sizing:
• #2 and #3 for adults
Advantages of the miller blade
Force, head extension, and c-spine movement is less
Great for smaller mouths and longer necks
What structures are visualized and how is the miller used to do so.
Complications of being too far or withdrawing?
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If withdrawn too far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
Technique for laryngoscope insertion including position and advancement
- “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
What is the atlanto-occipital level and significance for intubation
imaginary line btwn external auditory meatus and sternal notch
• 85° extension of atlanto-occipital level
Why is the scissor technique used with DL and what is most important to note with using this technique
- keeps lips free
- to accommodate blade insertion
- right hand opens mouth “scissor”
- Remove hand once blade inserted
What may be require for a difficult airway
• may require the use of a flexible fiberoptic scope
What is the design and advantage of the fiberoptic scope for difficult airway
Design
• with glass fiber bundles in the scope
• a camera view
Advantage
• allows identification of landmarks
• facilitates intubation
How is the fiberoptic scope used for a difficult intubation
- neutral position
- need a fiberoptic scope oral airway
- can be awake or “asleep
Why is positioning important for intubation? How is optimal position achieved?
- 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
What is the design and purpose of the bullard laryngoscope? When may it be useful?
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
What were advantages of the bullard (3)
- helpful in difficult intubations
- causes less cervical spine movement than direct laryngoscopy
- more rugged than fiberoptic scope
What were disadvantages of the bullard (5)
- 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
What is the design and purpose of the Wu Scope? How was insertion achieved?
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
Advantages of the Wu scope (5)
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
Disadvantages of the Wu scope (3)
Disadvantages
• high initial cost
• requires experience
• have been largely replaced by video laryngoscope
What are examples of rigid indirect laryngoscope
Bullard
Wu
Shikani
What is the design of the shikani optical stylet
Lighted stylet w/ malleable distal tip
Has an eye piece
O2 port
How is the shikani used for intubation. Sizing.
- 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
Advantages of shikani optical stylet
Difficult airway Not as invasive Easy to use O2 port Didn't require special patient positioning Smaller profile
Disadvantage of the shikani optical stylet. How is this prevented?
Stainless steel stylet
Very careful when advancing into trachea to avoid injury
Prevented:
maintain light anteriorly to avoid injury
How is the lightwand different than the shikani
Shikani
has an eye piece
Uses indirect visualization
Lightwand
BLIND
What are advantages of video laryngoscopes (6)
- 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
Limitations of the video laryngoscope (3)
- requires video system
- portability varies
- If intubation is difficult must withdraw laryngoscope slightly***
When using a glidescope, what should the anesthetist do if intubation is difficult
Withdraw the tip of the laryngoscope slightly
To have an easier passage of ETT
In a pt with a mouthful of rotten teeth, what would be the best method of intubating.
Glidescope w/ thinner cover/profile and it is plastic
instead of stainless steel DL blade
What is the most frequent anesthesia-related claaim
Dental injury
What is most likely damaged and how is this prevented
Most likely damaged:
- upper incisors
- Teeth restored or weakened
Prevention:
- Teeth protectors
- Stay off the teeth
Describe how DL can contribute to cervical spine cord injury
aggressive head positioning esp neck extension
manual in-line stabilization
• do not rely on cervical collars
What other structures may be damaged during DL?
abrasions/hematomas
lingual &/or hypoglossal nerve injury
arytenoid subluxation
TMJ dislocation
What are complications of laryngoscopy
Dental injury
Cervical spinal cord injury
Damage to other structures (lingual/hypoglossal nerve injury, TMJ dislocation etc)
Swallowing/aspirating foreign body
What are the most prominent teeth to be injured during DL
Upper = R 7-10 L
Lower = R 26-23 L
What are reasons that breathing systems change resistance
- ID of tube
- tube length
- configuration changes
- connectors
Describe the tracheal tube design
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
What are the advantages of the RAE tubes
•Facilitate surgery around head and neck •Temporarily straightened during insertion •Larger diameter longer distance from tip to curve •Cuffed or uncuffed •Easy to secure
What are disadvantages of the RAE tube
- Difficult to pass suction/scope
* Increases airway resistance
In what procedure may an oral rae tube
tonsillectomy
When would a spiral embedded tube be most useful
in head and neck surgeries when there is a lot of movement
What are advantages and disadvantages of the spiral embedded tubes
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
What is the design of laser tubes and for what procedures are they used?
- 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
Why is a reflective ETT important in laser surgery
To prevent fire b/c of abundance of O2
Laser can ignite an airway fire
What are the disadvantages of laser tubes
Disadvantages
• Stiff and rough (SS)
• Difficult to pass stylet through (SS)
• Less resistant to laser if blood on tube (W)
What are laser tube cuffs filled with an why?
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
What will the anesthetist do with gases when lasers are used
Low FiO2
No N2O
Manufacturing requirements for tubes (10)
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
What are safety standards for tube markings (5)
- 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)
Describe the design of tracheal tube cuffs
Inflatable balloon near patient end of tube
• Will sit just past the VCs (distal to cords)
Resistant, thin, soft, pliable
What are the cuff requirements for tracheal tube placement and inflation. Considerations when using nitrous.
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
How long before tracheal necrosis d/t hyperinflation of cuff
30 min
What is the design of high-volume, low-pressure cuffs of tracheal tubes.
What types of tubes?
• 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
What are the advantages and disadvantages of the high-volume, low-pressure cuff
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
What is the design of low-volume, high-pressure cuffs of tracheal tubes.
What types of tubes?
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
What are the advantages and disadvantages of the low-volume, high-pressure cuff
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
What populations receive cuffed vs uncuffed tubes
cuffed = adults uncuffed = peds
Why are cuffed tubes used in adults
- accurate end-tidal gases
- decreased aspiration
- decreased pollution
- decreased risk of fire
What is the best indicator for ETT size and what are not
best = gender
female 7.0, male 8.0
Not indicators
age, race, height, weight, BSA
What is the guide for sizing ped tubes
(age/4)+3
Not on test…
Why are uncuffed tubes routinely used in peds
Airway anatomy is different
Cricoid is narrowest part vs adults
How are tidal volume and gas maintained when using uncuffed tubes for peds
Make sure airway pressure is not too high
maintain < 20 cmH2O to prevent leak
Smaller volumes, higher RR
What can cause changes in cuff pressure
- Use of N2O (check pilot cuff pressure)
- Hypothermic cardiopulmonary bypass (smaller volume, poor seal)
- Increases in altitude
- Coughing, straining, changes in muscle tone
What are the common controversies in the field concerning tracheal tube care and insertion
Stylets??
Securing??
Bite blocks/airways while intubated??
Is it bad to intubate the esophagus??
What are some ETT complications (6)
Trauma Esophageal intubation Inadvertent bronchial intubation Fluid accumulation above the cuff Upper airway edema VC granuloma
What is the biggest risk of intubation the esophagus
not identifying it and not correcting it
What can lead to trauma from ETT insertion and how can this complication be prevented
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
How can vasoconstriction and pre-dilation be addressed w/ nasal intubation
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
How can esophageal intubation be determined (5)
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
When is inadvertent bronchial intubation most likely to occur? What can it lead to?
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
What should be the depth marking for ETT in females, males and peds
Adults:
female = 21 cm @ teeth
Male = 23 cm @ teeth
Peds:
(age/2)+12 cm
PEDS NOT ON EXAM
How can fluid accumulation above the cuff complicate ETT use? Why is this dangerous.
blood can accumulate and clot in trachea
difficult to reach with yankauer suction
Can lead to laryngospasm upon extubation
Where can airway edema occur when using ETT
What populations are most affected and why
anywhere along path of tube
dangerous in young children
• cricoid cartilage completely surrounds subglottic area
• peak incidence between 1-4 y/o
When are airway edema signs most visible?
How can it be prevented?
earliest signs 1-2 hrs postop up to 48 hours postop
Prevention:
Avoid irritating stimuli, URI
adequate anesthetic depth (decrease airway stimulation)
How can VC granulomas occur w/ ETT use
What are the signs/symptoms
trauma, too large ETT, infection, excessive cuff pressure on or around VCs
S/Sx
persistent hoarseness, fullness, chronic cough, intermittent loss of voice
What population may be more prone to forming VC granuloma.
How is it treated?
Population:
common in adults; females
Treatment:
laryngeal evaluation, voice rest
What is a bougie and when is it used
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)
When are magill forceps used?
What are complications of magill forceps use
Primarily during nasal intubation
-To direct tube into larynx
Complications:
- Damage to cuff
- Lodge in murphy eye
What airway adjuncts should be readily available in every room.
Bougie
Magill forceps
When is lung isolation indicated?
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
Difference in right and left lung anatomy and how intubation is affected.
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)
What determines if double-lumen tube is right or left
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
What are the double-lumen tube types and sizes?
Which is primarily used?
Double-lumen tubes
• Adult sizes: 35, 37, 39, 41
• Pediatric sizes: 26, 28, 32
Primarily we use LEFT DLT
What procedures would a double-lumen tube be used?
- Pneumonectomy
- left lung transplantation
- left mainstem bronchus stent in place
- left tracheo-bronchus disruption
When is a right double-lumen tube used?
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***)
How are double-lumen tube placement confirmed
Like we confirm ETT intubation, then…
BOTH lungs isolated
fiberoptic examination performed
What are complications with DLT placement
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
Can a left DL tube be used to ventilate the right lung
Yes, the RUL will be ventilated w/ the left DLT
What is a benefit of the bronchial blocker vs DLT
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
What are indications for use of bronchial blockers
- 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
What are some difficulties with bronch-blockeres
• 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
What are some invasive airway techniques
Retrograde intubation Cricothyrotomy Quicktrach Tracheostomy Jet ventilation
When would an anesthetist resort to invasive airway techniques
failure to intubate and failure to ventilate
What is retrograde intubation
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
How is cricothyrotomy performed
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
What is the design and insertion of the qiucktrach
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
How is a tracheostomy performed and for what purpose
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
How is jet ventilation used with advanced airways
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
What is total body water composition and the 2 compartment compositions.
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)
What type of tissue are RBCs
cellular tissue
How does fluid exchange occur between compartments. What are different types of fluid exchange.
Fluid exchange across capillary beds
Types
- Diffusion
- Intercellular clefts
- facilitated diffusion
Describe diffusion and what molecules follow this exchange pattern.
Diffusion:
• Process by which solute particles fill the available solvent by movement from high concentration to low concentration
Molecules:
O2, CO2. H2O
Describe intercellular clefts and prominent ions that follow this exchange pattern.
- 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+
What is facilitated diffusion. What molecules utilize this transport method
- 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
What is osmosis
- 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
What are examples of high MW molecules. What can happen if the cross cell membranes
examples:
glucose, proteins
Cross membrane:
the get trapped
Dominant ICF and ECF cations
ECF=Na+
ICF=K+
How is fluid regulated via intake/output
Thirst
Urine output
How does thirst regulate fluid
- changes in body fluid tonicity
* changes in extracellular fluid volume
How does urine output help regulate fluid
- 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
How is ADH managed. What happens if there is too much or too little.
Osmotic receptors in hypothalamus detect changes in osmotic pressure
Regulates release of ADH
Too little=diuresis
Too much=retain
What are other factors for ADH release
Stress Nausea Opioids Hypoxia Pain
When can ADH release begin
Blood volume loss of 5-10%
How does atrial natiuretic peptide (ANP) affect fluid regulation
acts on inc Na and volume with inc renal Na excretion
Na LOSS
How does aldosterone affect fluid regulation
acts on dec Na and volume with renal Na and water conservation
How does aldosterone affect water regulation
High aldosterone = fluid retention
Low aldosterone = fluid loss
How is H2O managed in the kidneys
Delivery of tubular fluid to diluting segment of nephron
Separation of solutes and water
Variable reabsorption in collecting duct
What is the most common delivery problem in the kidneys r/t H2O management
Delivery of tubular fluid to the diluting segments of the nephron d/t hypotension
Leads to AKI
What are 6 principles of fluid management
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
What type of volume change do anesthetics cause
Relative hypovolemia d/t widespread vasodilation causing hypotension
Fluid may have been redistributed
How are fluid management principles used to guide patient care and what warning should be heeded
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)
What is a crucial part of preop pt assessment
A crucial part of your pre-op assessment
will involve evaluation of fluid and electrolyte balance!!
What are basic guidelines of maintenance fluid requirements
Water requirement is proportional to metabolic rate
During a 24 hour period- water in = water out
Where does fluid loss occur typically? Difference in sensible and insensible?**
Losses: skin, urinary, GI, respiratory tract
• Insensible losses (skin + resp, open abd) 25-30%**
• Sensible losses (urine + GI) 70-75%**
What is normal average daily intake and output
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
What is traditional hourly maintenance calculation***
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
What are the NPO guidelines***
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
What have current studies determined about NPO guidelines***
- preop fasting overnight for approx 10 hrs, does not significantly reduce intravascular volume***
- again based on patient!!
How can dehydration be avoided during preop fasting
- by limiting the fasting period
- the consumption of clear liquids
- recommended up to 2 hrs prior to surgery
What preop conditions can cause intravascular volume loss and why
bowel obstruction and pancreatitis
due to inflammation and interstitial edema
Calculate hourly maintenance and NPO deficit for a 178 lb male who’s NPO for 8 hrs.
Give hourly totals
hourly maintenance = 121 ml/hr
Deficit total = 968
1st hr = 484 (total 605)
2nd hr = 242 (total 363)
3rd hr = 242 (total 363)
54 minute video for fld mgmt
pg 14
What are alternatives to homologous blood therapy
autologous blood
What are benefits of autologous blood therapy. What are the 3 types
avoids complications of donor blood
conservation of resources
3 types:
Preop donation
Intraop hemodilutoin
Intraop recovery
What are the guidelines of pre-donation autologous donation
• 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
What are benefits for using autologous blood
Pt may get transfused w/ their blood at a higher h/h than for cases w/o autologous donation (she says “lower threshold”)
What are some things to consider with autologous blood donations
50% of this blood is discarded
wrong pt-wrong unit can still happen**
Less “questioning”
How is platelet dysfunction avoided in autologous donation.
How does this affect the blood and pt tissues.
- Temp maintained so no platelet dysfunction
- Increased tissue perfusion due to decreased viscosity
- Multiple studies show it decreases the need for donor transfusion
What is acute normovolemic hemodilution
When practitioner draws off blood to a hct of 28%
Provides volume expansion (3ml:1 ml crystalloid or 1:1 colloid)
What are storage considerations with acute normovolemic hemodilution
- No storage related complications
- Same room, no crossmatch
- Stored at room temp for up to 8 hours
- 8-24 hours refrigerated, then discard
How is acute normovolemic hemodilution performed
- 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
What are relative complications/contraindications to ANH
• Renal insufficiency • Pulmonary disease • Preexisting coagulopathy • Myocardial ischemia • Cerebral hypoxia sickle cell??
What is the process for cell saver and another name for it
aka Intraop blood recovery
Suction -> anticoag reservoir -> filter and wash -> centrifuge -> waste
What is given back to the patient when cell saver used
RBC only
plt, wbc, clotting factors and debris are all washed out
What is the purpose of cell saver use
• Oxygen carrying capacity > PRBC due to fresh and has not been cooled
What are some differences in ANH and cell saver blood return
ANH = whole blood
Cell saver = RBCs only; plt, wbc, clotting factors and debris are washed-out
What procedures would cell saver be useful
Long spine surgeries with larger blood losses • Cardiac • Vascular • Orthopedic (Becky??) • Trauma • Can be used in OB, need
What are complications to consider with the use of cell saver***
- Air embolism rare and procedure dependent
* Renal dysfunction from damaged cells (usually comes from excessive suction and poor washing)
What are some considerations when utilizing cell saver for blood therapy
• 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
What may not be washout from blood when using cell saver
Not all bacteria
Tumor cells may remain
What are contraindications for cell saver use??
???
What are disadvantages of cell saver use
- It is expensive
- Trained person
- Device
- Disposables
What is the golden rule for NPO defecit replacement
1st hour = 1/2 of deficit
2nd hour = 1/4 of deficit
3rd hour = 1/4 of deficit
What are preexisting deficits caused by abnormal fluid losses
- Preoperative bleeding
- Vomiting
- Diarrhea
- Diuresis
- Fluid sequestration (trauma/infection)
- Bowel prep
- Fever
What are preexisting disease caused fluid loss
- Ascites
- HTN
- DM
- Bowel obstruction
- Peritonitis
- Burns
- Shock
What are the burn fluid guidelines
• Burn fluid therapy
2-4 mL/kg/% burn first 24 hours
What are the guidelines for fever and fluid deficit replacement
• 10C fever = ↑ fluid deficit 10%
What is the goal of deficit fluid replacement***
The goal
to correct fluid and electrolyte imbalance
Timing is everything!!
What signs on the physical exam can indicate fluid defecit
Skin turgor Hydration of mucous membranes Peripheral pulses Orthostatic hypotension Urinary flow rate
At 5% deficit, what aspects of physical assessment are affected and to what degree?
mucous membrane = dry sensorium = normal orthostatic = none B/P = no change Urine = mild decrease Pulse = slight increase
At 10% deficit, what aspects of physical assessment are affected and to what degree?
mucous membrane = Very dry sensorium = lethargic orthostatic = present B/P = no change Urine = Decreased Pulse = >100 bpm
At 15% deficit, what aspects of physical assessment are affected and to what degree?
mucous membrane = parched sensorium = obtunded orthostatic = marked B/P = Dec >10 mmHg Urine = marked decrease Pulse = 120 bpm
What are some assessment clues that hypervolemia is present
Pitting edema Presacral, pretibial edema Increased urinary flow Tachycardia Pulmonary crackles Wheezing Cyanosis, pink frothy resp secretions
What are lab value clues for hypo/hypervolemia
Hypovolemia*** • Rising Hct • Progressive metabolic acidosis • Hypernatremia • BUN:Cre > 10:1
Hypervolemia***
• X-ray changes
• Increased vascular and interstitial markings
• Diffuse alveolar infiltrates
When should fluid bolus/challenge be considered for fluid management
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
What are the general principles of maintenance fluid administration.
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
What are metabolic requirement of glucose
4 mg/kg/hr
What are 2 types of intraop fluid loss
Evaporative loss
Internal redistribution
What are evaporative vs internal redistribution losses.
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
What are evaporative vs internal redistribution losses.
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**
Why and how do fluid shifts occur during anesthesia
Most anesthetic agents produce • vasodilation • relative hypotension Decreased SNS activity Reduce PVR Relative hypovolemia
What are can result from relative hypovolemia
Decreased SNS activity
Reduce PVR
- ~ 15% volume is arterial
- ~ 85% volume is venous
When is GDT typically used. What are requirements
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
What are some evidence based support for GDT
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
What are fluid administration guidelines with GDT. Maintenance fluid vs fluid loss administration.
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
What are monitoring guidelines for GDT. Why are they used?
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
In what types of cases are traditional fluid management used
- minimal fluid
- blood losses based on pt
- case presentation
What are the primary goals of fluid management?
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
What are the guidelines for redistributive and evaporative levels of losses
Minimal=0-2 ml/kg/hr (2)
Moderate=2-4 ml/kg/hr (4)
Severe=4-8 ml/kg/hr (6)
What replacement fluids can be used
Generally polyionic isotonic fluids
LR, Plasmalyte, NSR, NS (0.9%)
Fluids that closely mimic plasma electrolyte concentrations
What is the mOsm of the most commonly administered fluid during surgery
273-308 mOsm/L
What are some colloids, makeup and their benefits
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
Types of colloid fluids. Problems with colloids
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
What are reasons to consider colloids
Fluid resuscitation in patients
• with severe intravascular deficits p/t arrival of blood
Fluid resuscitation
• in the presence of severe hypoalbuminemia
Relative reasons to consider colloids
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»_space; 3-4 L
prior to transfusion
Albumin replacement
• after paracentesis 4-8 g/ L of ascites
• protein rich fluid removed
What are the half lives of crystalloid and colloids
Crystalloid intravascular ½ life
• 20-30 minutes
Colloid intravascular ½ life
• 1.5-6 hours
How is the benefit of fluid management measured
Urine minimum 0.5-1 ml/kg/hr
What is the problem using urine as a measure for fluid status
Increased ADH secretion d/t stress response PPV decreases VR– CO – GFR SNS activation of ANP Positioning Intraabdominal pressure
What measures should be used to assess fluid management vs UO
Stroke Volume Variation Ultrasound TEE ABG DO2I 600ml O2/m2/min
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…
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
How is allowable blood loss calculated
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
What are the ml/kg for estimated blood volume
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
Calculate the ABL for 70 kg woman w/ HCT 38%
What is her blood volume, RBC volume and her estimated normal RBC volume?
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
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
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
What is consider when calculating EBL
Surgical suction canister Fully soaked sponge (4x4) = 10 mL*** Fully soaked laparotomy pad = 100-150 mL*** Irrigation Drapes Oozing
Guidelines for blood administration
Few practitioners use absolute numbers for transfusion
hgb ≥ 8 NO
hgb ≤ 6.0 YES
8 − 6 ?
What is the general increase in hgb and hct for adults and peds w/ 1 unit of RBC
1 unit PRBCs
• ↑ hgb 1 g/dL
• ↑ hct 2-3%
Peds w/ 10 ml/kg PRBCs
• ↑ hgb by 3 g/dL
• ↑ hct by 10%
What is blood loss replacement w/ crystalloid ratio
Blood loss is replaced with crystalloids at 3:1mL
What are different types of blood component therapy
Whole blood
-Colloids, clotting fators, platelets, RBCs
Packed RBCs (whole blood - plasma = RBC)
Drawbacks to stored blood
Reduced O2 carying capacity
Diminishing clotting effectiveness
When are PRBCs useful
- Useful in treating anemia
* High risk of fluid overload t/f Reduced risk of fluid overload, stays intravascular
What has a greater likelihood of causing tachycardia, anemia or hypovolemia
Hypovolemia
assess for hypovolemia
What are additives to PRBCs and their purpose
Contains citrate • binds the Ca++ Phosphate • as a buffer Dextrose • for fuel
Storage and administration guidelines for PRBCs
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
What is the minimum UO per hour for a 225 lb man. Minimum for a 3 hr case
51 ml/hr
153 ml for 3 hrs
Why is the ABL result multiplied by 3
Because the 3x takes into consideration whole blood volume loss vs only RBC volume loss
What does ABL indicate
The amount of blood los at which tissue isn’t receiving adequate O2
• When a pt may become symptomatic
Why is EBL calculation smaller for obese pts
Greater total blood volume BUT increased adipose tissue with LESS perfusion
What is the problem if HCT is <30% in relation to ABL
There is NO threshold for blood loss
May need to transfuse prior to surgery
What acid-base disturbance can be anticipated with pts having bowel preps prior to surgery
metabolic acidosis (ALKALOSIS) from chloride loss
What can excessive blood product administration do to heart rhythm and why.
Treatment
Can prolong QT interval d/t low Ca++ from binding with citrate from blood transfusion
Give calcium chloride (0.5 -1 gm)
What is the difference between type and screen and type and crossmatch
type and screen = blood type NO blood prepared or matched
type and cross = blood type AND donor blood match and prepared
What is universal donor
O neg
What conditions would FFP be used to treat (5)
- Clotting factor deficiencies
- Reversal of warfarin
- Correction of coagulopathy
- Dilutional coagulopathies
- Trauma; massive transfusion protocols
What are transfusion guidelines for FFP with other blood products
• 1st give 4-6 units of packed RBCs
• Then give 1:1:1 (RBC/FFP/Platelets)
Making whole blood
What is the makeup of FFP and storage guidelines
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
When are platelets used
thrombocytopenia
dysfunctional platelet conditions
What makes up a unit of platelets vs whole blood
How does 1 unit of plt affect plt counts
- 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
Guidelines for plt levels and surgery
• 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
What are other types of clotting assistance
Cryoprecipitate: concentrated fibrinogen, Factor VIII & Von Willebrand
Recombinant Factor VII: activates factor X, converts prothrombin to thrombin
What are some causes of bleeding in surgery
Surgical / Trauma
Severe Hypothermia (affects clotting cascade)
Coagulopathy (can be affected by hemodilution)
What are causes of hemolytic reactions to transfusions
Unknown cause Nonhemolytic TRALI (trxfn related acute lung infxn) TACO (trxfn acute circulatory overload) sepsis HIV
Awake vs asleep s/sx of hemolytic reactions
awake: • Chills • Fever • Nausea • Chest pain • Flank pain
Asleep: • Tachycardia • Hypotension • Hemoglobinuria • Diffuse oozing • DIC • Renal failure • Shock
What signs and symptoms are evident at 50%, 30% and only 5 gm of blood volume
50% remains
pt conscious
30% loss
grey, ashy with cyanotic extremities
5 gm of hgb
cyanosis
time = 1:00::55
fluid mgmt 2 (2nd)
pg 18
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
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
What is DO2I and the components for calculation
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)
What is the DO2I equation
- CaO2 = (1.34 x Hgb x SaO2) + (PaO2 x 0.003)
* DO2I = CI x CaO2 x 10
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
- 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
What What may a low DO2I in an asymptomatic pt with a borderline H/H indicate
The pt could still be bleeding
what does insufflation mean
use of CO2 to inflate an area in order to optimize surgical exposure and visualization
Describe the process of laparoscopy vs open methods
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
what are some effects of insufflation
Release at onset of pneumo-peritoneum • catecholamines • vasopressin Compression of arterial vasculature • Hypotension Decreased FRC
At what pressure should insufflation be maintained
IAP = 20 mmHg
What are the benefits of insufflation to create a pneumoperitoneum
- More space for surgeon to work with trocars
- increase visualization of structures
- avoids being so close to heavy vasculature
Pulmonary effects of insufflation.
alterations to compensate for Vm changes
- dec compliance 30-50%
- inc PIP
- dec FRC
- inc Vm 20-30%.
- inc PaCO2
- diaphragm elevation
- cephalad displacement of carina causing endobronchial intubation
What is the purpose of not ventilating > 20 cmH2O
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
What are some lung protective strategies when abd is insufflated
- pressure control ventilation
- -can use pressure >20 cmH2O ok w/ ETT NOT LMA or mask
- inc RR
What causes inc PaCO2 r/t insufflation
- abd distention
* CO2 gas absorption w/ plateau @10-15 min
How does diaphragm elevation affect pulmonary status during insufflation. How should these possible effects be monitored
Cephalad displacement of carina
• can result in endobronchial intubation!
• Monitoring after position change and insufflation
Monitor position of ETT
Bilateral breath sounds
Pulse oximetry
What are pulmonary complications with laparoscopic insufflation
- 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
What are hemodynamic effects of insufflation
• Decreased CO at onset of insufflation • Elevation of SVR and PVR • Arrhythmias • •
Why is CO affected by insufflation
b/c dec VR d/t compression on abd vena cava
How can SVR and PR d/t insufflation be treated
- Dilating anesthetics, b-blockers, remi
- Limit insufflation pressures
- dec tburg angle
What may occur to cardiac rhythm during insufflation and how can this be treated
- can develop cardiac arrhythmias that doesn’t correlate w/ PaCO2 level
- give glycopyrolate
What can lead to a gas embolism, what are s/sx and how is it treated
• 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
What are supportive measures for gas embolism
await absorption of CO2
maintain CO
What are position effects when head up vs head down
What can lithotomy positioning lead to
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
What is the benefit of Tburg position during lap procedures
displaces organs cephalic and allows for better exposure and visualization of organ to be operated on
Describe nerve injury r/t laparoscopic positioning for surgery
can cause nerve injuries to
Brachial plexus
• Overextension of arm
Shoulder support
Peroneal nerve (foot drop) • Lithotomy position
What are advantages of laparoscopy vs laparotomy.
What does this result in
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)
What are surgical complications of laparoscopy
Intestinal injuries: perforations, CBD injury Vascular injuries Burns Infection Contraindicated w/ inc ICP
What are the specific problems w/ these complications
Intestinal injuries: perforations, CBD injury
Vascular injuries
Burns
Infection
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
Why is laparoscopy contraindicated in presence of high ICP. List some conditions
inc ICP even more d/t inc and pressure and positioning and CO2 effects (cerebral vasodilation)
Conditions
tumor, trauma, hydrocephalus
Anesthesia considerations for laparoscopy
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
Postop considerations for laparoscopy
Oxygen
Prevention of nausea and vomiting
Treatment of surgical pain or referred pain
—shoulder pain r/t gas irritation of diaphragm
SCIP considerations for laparoscopy
Why are they in place
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
What are indications for fundoplication.
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
Preop considerations and rationale prior to fundoplications. Any specific meds?
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
Intraop anesthesia considerations for fundoplication
Preop meds GETA/RSI OGT Position • Supine, low lithotomy, reverse Tburg SCIP antibiotics Esophageal dilator (60 fr) = for strictures
What type of induction is performed with fundoplication sx and why
RSI
d/t severe reflux to prevent aspiration
What position is pt in for fundoplication and why
Supine, low lithotomy, reverse Tburg
• b/c reflux, better exposure for surgeon
Indications for cholecystectomy
- Symptomatic cholelithiasis (stones)
* Symptomatic cholecystitis (inflammation)
What are preop considerations for cholecystectomy
- Many emergent
- Full stomach
- Prokinetics
- Bicitra
What induction method would be useful in cholecystectomy
RSI b/c pmts considered to have full stomach
Intraop considerations for anesthetist during cholecystectomy procedure
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
How is pt positioned for cholecystectomy and why
• Supine, reverse Tburg, left tilt
Why:
To expose gallbladder on the right
Why is IOC performed and how.
What can it lead to
- 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
Why is an ecrp performed
to remove retained stones following cholecystectomy
prone case
GETA
Indicatins for splenectomy
- Normal or slightly enlarged spleen size
- Immune thrombocytopenia
- Lymphoma
- Hemolytic anemia
- Trauma
Preop considerations for its undergoing splenectomy
Immunizations (1 week) • Pneumococcal • Meningococcal • H influenza vaccinations Evaluate LLL atelectasis • r/t spleen location
why is vaccination important w/ splenectomy
b/c pt will become immunocompromised
Intraop considerations for splenectomy
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)
indications for bowel resections
- Ulcerative colitis
- Crohn’s disease
- Diverticular disease
- Cancers
Preop considerations for bowel resections
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
Intraop considerations for bowel resections
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
What induction method is used for bowel resection
RSI and GETA
Appendectomy indications and preop considerations
Suspected appendicitis or rupture (s/s?)
Consider full stomach
May be dehydrated d/t fever/N&V
• Hemoconcentration
Intraop considerations for appy
GETA/RSI? • Consider full stomach/aspiration risk OGT Position • Supine, left arm tucked; trendelenburg SCIP antibiotics Laparoscopic (can convert to open esp for rupture)
S/sx of appendicitis or rupture
ruq pain?? (rlq??) rebound tenderness n/v dehydration hemoconcentration inc BUN
What surgical method may be used w/ appy
laparoscopic
open if ruptured
What induction method may be used w/ appy
RSI d/t full stomach
Indications for bariatric surgery
Morbid obesity associated with BMI > 35 • with associated comorbidities • HTN • DM • OSA • Asthma BMI > 40
Preoperative concerns prior to bariatric surgery
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!!!
Intraop anesthesia considerations for bariatric surgery
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
What type of induction is best for bariatric sx pts and why. What should be monitored
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
What are some long-term concerns following bariatric sx
Diarrhea Dysphagia Protein malabsorption • Less contact time • less bile/pancreatic enzymes Vitamin malabsorption • A,D,E,K,B12,calcium
Advantages and disadvantages of robotics surgery
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??
Intraop considerations during robotic cases
General anesthesia NMBD • Positioning and staying there!!! • Good muscle relaxation SCIP antibiotics • Fluid restriction!!!
Indications for conversion to laparotomy
- Obesity
- Adhesions
- Bleeding
- Unclear anatomy
- Staple misfire
- Inability to ventilate
- inability to insufflate
Indications for Ex-Lap
- Trauma
- Abdominal catastrophes
- Staging (cancer spread and tissue samples)
Intraop considerations for Ex-Lap
- GETA
- Profound muscle relaxation
- NGT
- Consider epidural placement
- Consider multi-modal pain control
What are concerns considered when converting to laparotomy
- -increase intraop fluid loss
- -increase OR time
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
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)
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?
crystalloid = 1500 ml
colloid = 500 ml
What should total urine for 91 kg pt in 4.5 hr case be
205 - 410 ml total
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
(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
Purpose of insuflflation in gyn surgeries
Intraperitoneal insufflation of CO2 intraop
IAP = to 20 mm Hg
Identification of intraperitoneal space
• open versus closed
Physiologic changes associated with pneumoperitoneum
Ventilatory changes due to insufflation during gyn surgeries
Decreases compliance by 30-50% Decreases FRC Increases airway pressure Increases PaCO2 Supports the development of atelectasis
Ventilatory complications due to insufflation during gyn surgery
SQ emphysema (trocar placement)
Pneumothorax, pneumomediastinum
Endobronchial intubation
Gas embolism
CV changes due to insufflation during gyn surgeries
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
When can arrhythmias occur with insufflation
when insufflating too fast with too high pressure
how does position affect pt during gyn surgeries. What are typical positions for gyn sx.
Physiologic changes r/t positioning (affects FRC)
At Risk for
• CV and resp changes
• nerve injury
Typically lithotomy
• with trendelenburg/steep trendelenburg
Complications from gyn laparoscopic sx
Intestinal injuries • perforation, CBD injuries Vascular injuries Burns Infection Contraindicated with increased ICP
What are risk factors for postop n/v following gyn procedures
- Female
- laparoscopy < laparotomy
- opioids
- volatile anesthetics
Indications for d and c
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)
What can occur as a result of retained products of conception
increase risk for sepsis and blood loss
Anesthesia considerations for DandC
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
What is DandE
Anesthesia considerations
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
MOA for Pitocin and typical dose
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)
Indications for hysteroscopy and description of how procedure is performed
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
Anesthesia considerations for hysteroscopy
• 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
Considerations when sorbitol is used to inflate uterus during hysteroscopy
Possible osmotic issues
What is a paracervical block, when can it be used
During hysteroscopy (other procedures??)
Why are abx needed for hysteroscopy
b/c of fluid used to inflate uterus
Why is bradycardia a possibility w/ gyn surgeries
Vagal response d/t stretching of abd nerves (celiac reflex?)
Indications for urethral sling
What is used to secure sling
- Loss of support to bladder neck and pelvic floor
* Can use tape, animal muscle, ligament, tendon, prolene mesh
What can loss of support to bladder neck and pelvic floor lead to in women.
Who’s at risk and why
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
Anesthesia considerations for urethral string
Lithotomy position Enter through vag General anesthesia • usually LMA SCIP antibiotic Postoperative pain (cramping)
Indications and purpose of cervical ionization and how performed
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
Anesthetic considerations for cervical conization
Lithotomy position
Pregnancy test
• 10-15% loss in 1st trimester if pregnant
General vs sedation vs regional anesthesia
No SCIP antibiotic
Postoperative pain
What should be considered before blood administration as part of fluid management
When to give blood slide
- organ ischemia?
- ongoing bleeding
- VSS? or not
- What is cardiopulmonary reserve
What are varying methods for hysterectomy
• Abdominal (Pfannenstiel or midline incision)
• vaginal
• laparoscopic assisted vaginal hysterectomy (LAVH)
May do these with robotic techniques
Intraop considerations for hysterectomy
- -May have had bowel prep
- -potential for bradycardia
- -position = lithotomy or TBurg
- -General vs SAB vs epidural
- -SCIP Abx
- -Foley (keep bladder empty)
Gyn conditions that require gynecologic repair procedures
Cystocele- anterior prolapse (bladder)
Rectocele- posterior prolapse (rectum)
Enterocele- descension of small intestine
Why are gynecologic repair procedures performed
b/c pt has weakened pelvic floor d/t aging, deliveries or previous pelvic surgeries
Anesthesia considerations for gyn repair procedures
Lithotomy position General anesthesia SCIP antibiotic Postoperative pain Foley catheter (keep bladder empty)
Purpose of gyn cancer procedures
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
Considerations for anesthesia during gyn cancer procedures
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
What are genital condylomas
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
Considerations for anesthesia for genital condyloma procedures
Lithotomy position General anesthesia (LMA) Laser evacuation procedures • include smoke evacuation • designated particulate masks to avoid transmission- REQUIRED! No SCIP antibiotics Postoperative pain
Considerations for anesthesia during gyn robotic surgeries
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
Abdominal region of GU system innervation
• ANS via SNS and PSNS path
Pelvic region and genitalia innervation
• somatic and autonomic nerves
Kidney and ureter pain innervation.
Why is this important w/ regional techniques
referred via
•somatic distribution of T10 – l2
Regional importance
effective neural block is essential for T10-12
Bladder sensation/stretch/fullness vs pain/touch/temp innervation
Sensations of stretch and fullness
• PSNS innervation,
pain, touch and temperature
• supplied by SNS
In the bladder, what does the PSNS vs SNS innervate
PSNS
sensation/stretch/fullness
SNS
pain/touch/temp
Innervation of bladder base/urethra vs dome/lateral wall
Bladder base and urethra
• mainly alpha adrenergic
Bladder dome and lateral wall
• mainly beta adrenergic
In the bladder, what areas are innervated by alpha adrenergic vs beta adrenergic nerves
alpha
–bladder base and urethra
beta
–bladder dome and lateral wall
Prostate and prostatic urethra innervation and origin
SNS and PSNS
• from prostatic plexus
• spinal origin is lumbosacral
Penile urethra and tissue innervation
• ANS from the prostatic plexus
Scrotum innervation
- anteriorly = ilioinguinal and genitofemoral nerves
* posteriorly = perineal branches of the pudendal nerve
Teste innervation. Important considerations for regional technique
similar nerve supply to kidney and upper ureter extending to T10 • Important for regional nerve block For pain control To blunt surgical stimuli
Anesthesia considerations for renal and GU surgeries
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
Why is sensory innervation consideration important for GU surgery
innervation mainly thoracolumbar and sacral
regional anesthesia is common
• combination technique w/ GETA
• Very common
What does periop AKI depend on w/ GU surgeries
type of surgery preop kidney function treatment • medications • possible dialysis
Renal CV considerations intraop
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
How does SNS stimulation during surgery affect renal vasculature
- can increase RenalVR
- decrease renal bf
- on top of anesthetic effect of decreased CO
What can happen to kidneys w/ prolong hypotension and dec BF
• will decrease glomerular filtration rate (GFR)
if autoregulation is lost d/t INJURY OR DISEASE
more likely to have kidney injury intraop
Important renal consideration for its w/ autoregulation probs d/t prior injury or disease
decrease GFR
more likely to have kidney injury intraop
What is GFR and why is it important
- BEST MEASURE OF GLOMERULAR FUNCTION
* APPROX 125 ML/MIN
When is reduced GFR manifested
Renal issues at 30% dec GFR and 5-10% normal GFR
MANIFESTATIONS OF REDUCED GFR
NOT SEEN UNTIL «_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
how does BUN relates to renal function and GFR
- NOT A direct MEASURE OF GFR
- can be INFLUENCED BY NONRENAL VARIABLES
- ELEVATION DOES NOT OCCUR UNTIL GFR IS REDUCED TO ~75% OF NORMAL
how does crt clearance r/t renal function and gfr
• valuable b/c used as an estimate of gfr
direct relationship
Important considerations for pts w/ chronic renal failure
hypervolemia acidosis hyperkalemia cardiac/resp complicatoins anemia Does the pt make urine (foley) serial labs to assess fxn
Why is hypervolemia an important consideration for CRF pts
b/c they can’t filter properly, retain fluid, and won’t respond well to large amounts of fld
What effects does acidosis have on the CRF pt
How addressed
CRF can be corrected with dialysis
moderate RF pt can usually compensate
can become acidotic and hyperkalemic postop
Hyperkalemia considerations for pts w/ CRF, and moderate renal failure
Why does it happen
impaired k+ handling in the tubules -can be exacerbated by other factors hemorrhage metabolic acidosis medications
What are cardiac and respiratory complications to consider for CRF pts and why
Htn
pulmonary congestion and edema
r/t intraop fld overload
What causes anemia in CRF pts, why is this important to consider and possible treatments.
Contributions to abnormal bleeding
d/t lack of erythropoietin production
treatment
iron
erythropoietin
abnormal bleeding times and coagulopathies Treatment Desmopressin Cryo rbcs conjugated estrogens
How can an AKI be determined in a CRF pt that doesn’t make urine
assess labds
bun/crt etc
Medications used for CRF pts periop
opioids inhaled anesthetics propofol succs (assess K+) Nondepol NMB (cisatracurium is renal protective??) Cholinesterase inhib (can reverse) antihypertensive pressors
Indications and method for performing TURP
Indications
• Nodules begin to develop in the 40’s
• most commonly performed for bph
Method
• Resection of prostatic tissue
• metal loop
• laser
Risks when having TURP
- Bleeding
- Dvt
- bladder perforation
- mi/stroke
- renal failure
- infection
- complications from absorption of irrigant
Considerations when inc bleeding occurs w/ TURP
if uncontrolled bleeding • Terminate TURP 1st • give blood products as needed • foley with traction inserted ---- to tamponade bleeding
What can extensive resection or capsular compromise lead to
• can increase bleeding
Considerations for EBL r/t TURP. Why
• difficult to measure
• often inaccurate
—-d/t constant irrigation
advantages of laser TURP
has decreased complication r/t blood loss irrigant Improved outcomes Less time
BUT
can still cause urinary tract or bladder perf
Method of laser TURP
laparoscopic or robotic
position = lithotomy and steep TBurg
What is the purpose of irrigation for TURP
What is the ideal solution
Purpose of irrigant
• Improve visualization
Ideal irrigant solutions • Isotonic • electrically inert • nontoxic • transparent • inexpensive • does not exist!
Most commonly used irrigant and administration considerations
moderately hypotonic-
glycine, mannitol, and Cytal
Should be warmed
• help prevent hypothermia
Considerations w/ glycerine use in TURP
Glycine solutes can cause
myocardial depression
CNS
retinotoxic side effects
Irrigant common to bipolar and laser TURP
techniques with NS
helps minimize irrigant complications
How are complications minimized r/t irrigant when performing laser TURP
decreased time of surgery leads to increased use of irrigant
Prostate vascular considerations when performing TURP r/t irrigant absorption
what is absorption dependent on
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
Complications r/t irrigant use w/ TURP
Excessive reabsorption
Overhydration
TURP syndrome
What can excessive reabsorption lead to
Why is over hydration a concern
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
What causes TURP syndrome, presentation and treatment.
Complications of identification in awake vs asleep pt
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
Anesthetic technique possibilities for TURP
Spinal
GETA
Regional
Considerations for anesthetic technique is dependent upon
Prostate: Size Vascularity (big = more) duration of surgery presence of inflammation or infection
Advantages of spinal in TURP
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
When would GETA be used in TURP sx
patients who need respiratory or hemodynamic support
contraindication to regional
Advantages of regional in TURP sx
-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
What anesthesia techniques can be combined for TURP
GETA and regional
GETA and spinal
How does regional use in TURP help mitigate fluid overload
helps keeps fluid in vasculature
Common positioning for TURP and common nerve injuries
lithotomy
slight to steep TBurg
Nerve injuries
common peroneal
sciatic,
femoral
Mortality rates s/p TURP
similar between regional w/ sedation and geta When differences are evident longer cases larger glands increased age in favor of regional
Indications and risks for lithotripsy
Indications
used for ureteral stones low in the ureter
Risk
ureteral damage/perforation
keep well hydrated
hematuria expected postop
Anesthetic technique used w/ lithotripsy
geta with paralysis
typically used
to avoid movement,
regional used
level should be t8-t10
Indications and risk(5) with extracorporeal shock wave litho
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
Anesthetic techniques used w/ ESWL
GETA w/ paralysis
• to avoid movement,
Regional use
Flank infiltration with local with tIVA
What else may surgeon incorporate when performing lithotripsy
Cystoscopy Concern w/ ureter/bladder perf stone manipulation stent placement To maintain UO may affect anesthetic choice
contraindications for lithotripsy
Pregnancy
untreated bleeding disorders
Types of radical GU surgeries and method used to perform
Types
• Radical nephrectomy
• radical cystectomy
• radical retropubic prostatectomy
Methods
• laparoscopic
• robotic
• depending on best outcome for patient
General intraop considerations for radical GU sx
long procedures with large blood loss potential for decreased renal function • also CO2 insufflation increase risk of increased intrathoracic CO2 accumulation treat inc ventilation
Most common GU malignancy and associated procedure
• Most common malignancy of kidney is renal cell carcinoma
• Treatment
radical nephrectomy
partial nephrectomy
Commonly used anesthetic technique for radical GU surgery
Geta preferred
Regional
especially for postop pain management
Common injuries r/t position during radical GU sx
- Common injuries
* cervical plexus, brachial plexus, common peroneal
Radical nephrectomy positioning and risks
flank/lateral position
risk of dependent atelectasis
kidney rest helps w/ exposure can decreased bp compress the vena cava reducing venous return
RCC tumor complications
5-10% of pts w/ RCC tumor
extends into the renal vein
the inferior vena cava
right atrium (more common in right side RCC)
Risk associated with radical nephrectomy for RCC tumor
circulatory failure
• from complete VC occlusion
PE
cardiopulmonary bypass possible
Indications and possible structures removed w/ radical prostatectomy
Indications= for localized prostate cancer
Removal of Prostate ejaculatory ducts seminal vesicles part of bladder neck pelvic lymph nodes
Risks and anesthetic technique for radical prostatectomy
Risks w/ open radical prostatectomy
hemorrhage
massive blood loss
Anesthetic technique
GETA
Regional
especially for postop pain management
Pt position when performing robotic radical prostatectomy and associated risk
lithotomy, steep Trendelenburg increased risk of • nerve damage • pneumoperitoneum • Risk of CO2 absorption
What are risks of steep TBurg
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
Anesthetic technique used for robotic radical prostatectomy and why
GETA/Muscle relaxation
To prevent visceral or vascular injury during robotic procedures
Urogenital pain syndromes can be a result of (5)
- Infection
- anatomic anomaly
- obstructive uropathy
- nerve compression/damage
- malignancy
Concerns with benign renal tumors and treatment
usually presents with flank pain can affect renal function potential for • rupture • hematoma formation
Treatment
• Symptomatic
• tylenol/neuromodulatory agents
Renal cell carcinoma classic triad, pain presentation and treatment
classic triad
• hematuria
• flank pain
• renal mass
pain can indicate metastatis
• poor prognosis
treatment can include
• intercostal nerve blocks
• intrathecal opioids
• neurolysis
Types of infectious renal disease and treatment
pyelonephritis and perinephric abscess
• presents with fever
• assess inflammation of surrounding organs/infection
treatment
• antibiotics
• Or surgery
What is pseudo renal pain syndrome and treatment
from compression, damage, or entrapment
• of nerves of urinary system
treatment
• nerve blocks
• anti-neuropathic drugs
What is polycystic kidney disease, causes(6) and treatment(4)
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
What is interstitial cystitis, presentation, and treatment
painful bladder syndrome
presentation
• chronic suprapubic pain
• urinary changes
treatment •focuses on pain relief modalities meds nerve stimulators •possible surgery •Abx
What are urothelial tumors, presentation and treatment
most commontransitional cell carcinoma of the bladder
Presentation
• painless hematuria
• possible bladder irritability
treatment
•surgery
•pain management
Nsaids, tylenol, opioids
What is most common prostate cancer, presentation and treatmetn
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
Cause of prostatitis and treatment
Cause
• inflammation
• usually from infection
• can be chronic
treatment • antibiotics • antiandrogens • NSAIDs • pelvic floor physiotherapy
Testicular pain causes and treatment
Causes • trauma • torsion • infection • tumor tumors are usually painless
treatment
• surgery
• pain relief modalities
What is priapism and the treatment
- prolonged erection over 4 hrs
- ischemic (medical emergency) vs nonischemic
treatment
• penile nerve block
• followed by blood aspiration
for ischemic priapism
What is Peyronie’s disease and treatment
severe penile pain with intercourse
• due to curvature
treatment
• surgery
• NSAIDs
What is vulvodynia and treatment
- chronic pain due to
- sexual inactivity
- dysfunction causing vulvar pain
treatment • tricyclic antidepressants • sitz baths • estrogen creams, • pudendal nerve blocks
What is dyspareunia, possible causes and treatment
- 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
What can lead to chronic pelvic pain and treatment
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
List conditions that can lead to GU pain syndromes (15)
- 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
What is the principle behind ultrasound
the idea of “seeing” using sound waves
Historical uses of ultrasound
1974 Spallanzani discovered Bats used US
Used by military
1950s began use In medicine
-mostly obstetric
Advantages of US
- ID anatomic structures (especially deep)
- inc accuracy of access etc
- May decrease time
- may decrease complications
Principles of US wave travel and reflection
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
