E3- General / Gynecologic Surgery Flashcards
1
Q
When was laparoscopy first used? What for?
A
- 1970’s for gynecologic conditions
- Cholecystectomy – Late 1980’s
2
Q
What is the purpose of gastric insufflation?
A
- Allows for room to work + equipment
- identification of intraperitoneal space
3
Q
What occurs with the onset of pneumoperitoneum insufflation of the abdomen?
A
- Release of catecholamines & vasopressin»_space; increase SVR
- Arterial vasculature is compressed
4
Q
What is the goal pressure in mmHg for gastric insufflation?
A
≤ 20 mmHg
12 - 15 mmHg is most common.
5
Q
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What causes increased CO₂ during laparoscopic surgeries?
A
- Positioning (frequently Trendelenburg)
- CO₂ insufflation (absorbed by peritoneum into the blood stream).
6
Q
What are the pulmonary effects of insufflation?
A
- ↑ PaCO₂
- ↓ compliance
- ↑ PIP
- ↓ FRC»_space; dec Vt
- Atelectasis
7
Q
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In what laparoscopic position is atelectasis development most common?
A
Trendelenburg
8
Q
How much change in pulmonary compliance occurs with gastric insufflation?
A
30 - 50% decrease in compliance
9
Q
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Is increased PaCO₂ in laparoscopic cases primary from diaphragm displacement or CO₂ absorption?
A
Primarily from diaphragm displacement.
10
Q
When does the increase in PaCO₂ from gastric insufflation plateau?
A
after 10 - 15 min
11
Q
How does the CRNA typically treat hypercarbia secondary to gastric insufflation?
A
- increase Vm
- ↑ VT or RR
12
Q
When would the CRNA be hesitant to treat a hypercarbic patient?
A
Towards the end of the case.
↑ CO₂ necessary to stimulate pt’s respiratory drive and facilitate extubation.
13
Q
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What typically causes pulmonary complications in laparoscopic cases?
A
Improper trocar placement
14
Q
What are the pulmonary complications associated with improper trocar placement?
A
- SubQ emphysema, pneumothorax - into chest
- Gas embolism - into vessel
15
Q
When does Subq emphysema usually resolve?
A
In 30-60 min
16
Q
What pulmonary complication is the result of CO₂ insufflation pushing the carina upwards?
A
endobronchial intubation
17
Q
What’s the hemodynamic result of a gas embolism into the vena cava?
A
Massive CO drop
obstruction to venous return
18
Q
What are the s/s of gas embolism?
A
- ↓ EtCO₂ (best early sign)
- tachycardia
- Dysrhythmias
- hypotension w/ ↑ CVP
- Millwheel murmur
- Hypoxemia
19
Q
What is the treatment for CO₂ gas embolism?
A
- Cessation of insufflation
- Trendelenburg w/ L lateral tilt
- Fluid bolus
- 100% O₂
- Aspiration of air
- Vasopressor support
20
Q
How is endobronchial intubation detected?
A
- Loss of bilateral breath sounds
- ↓ pulse oximetry
21
Q
At what intraperitoneal pressure do the hemodynamic effects of insufflation set in?
A
> 10 mmHg IAP
22
Q
What hemodynamic changes are seen with insufflation?
A
- ↓ CO
- Reflexive ↑ BP
- Reflexive ↑ SVR/PVR
23
Q
What drugs would be best for the hemodynamic effects from CO₂ insufflation?
A
Vasodilting agents
- Voltailes
- Nitroglycerin
- Cardene
- Remifentanil
- Esmolol
short acting
24
Q
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How much do cardiac arrhythmias increase with increased PaCO₂?
A
Trick question. Arrhythmias arise from hypoxia not from hypercarbia.
25
What do cardiac arrythmias correlate with?
Not correlate with? 3
* young females
* PaCo2 , length surgery, bp
26
What are the cardiac arrythmias seen d/t insufflation?
severe bradycardia to asystole
27
What often causes cardiac arrythmias in laparoscopic cases?
Increases in vagal tone
- Peritoneal/cervical stretch
- Pulling on cervix
- electrocautery/stretch fallopian tubes
28
How would the bradycardia from vagal stimulation be treated?
- Limit insufflation pressure
- Glycopyrrolate
29
Position effects of Reverse Tburg + Tburg?
* venous stasis, dec CO ... good ventilation
* edema , increase CO/CVP , increase IOP , decrease FRC/TLC/compliance
30
In what position would one expect possible injury to the peroneal nerve or even compartment syndrome?
Lithotomy
31
What is the most common surgical complication of laparoscopy?
Whats the occurence?
- Intestinal injury :: perforation, CBD injury
- 30-50%
- May remain undiagnosed
32
What are the possible surgical complications of laparoscopy?
- Intestinal injuries :: 30-50%
- Vascular injuries
- Burns :: 15-20%
- Infection :: very small
33
When is laparoscopy contraindicated?
Patient with ↑ ICP (tumor, trauma, hydrocephalus)
34
Is LMA a good option for Laparoscopic procedures?
Not really, insufflation can displace the LMA.
35
What are the reasons for OGT/NGT insertion in laparoscopies?
Aspiration of stomach air so surgeon has better visualization.
Decompression
NGT = if needed postop or convert to laporotmy
36
Why is it important to discuss referred pain?
Belly surgery + have bad shoulder pain
gastric insufflation after case - CO2 rise + irritate diaphragm = shoulder pain
37
What important part of the SCIP protocol is anesthesia in charge of now?
Antibiotics within 1 hr of cut time
38
What are the two most common firstline antibiotics indicated by the SCIP protocol?
- Cefazolin 1-2 grams
- Cefoxitin
39
What is the most common antibiotic indicated by the SCIP protocol for those with severe penicillin/cephalosporin allergy?
Vancomycin : 1-1.5 grams
40
What are the other factors important to the SCIP protocol besides antibiotics?
- β-blockers : within 24 hrs
- Temperature : >36 C
- Time Out : prior to incision
41
5 Indications for breast surgery
biopsy - excision of lesion w/ margins
lumpectomy - partial mastectomy - 2.5-5cm lesion
simple mastectomy - breast + nipple
Modified radical - breast, nipple, axillary lymphnodes
Radical mastectomy - breast, nodes, pectoralis muscle
42
Breast Preop: Why evaluate cardiac/pulm?
Pregnancy test!
chemo/radiation given prior
43
# Breast
Wire localizarion
of area of concerns
Wire put in under radiology guidance
Do not pull out ,, just don’t touch it
44
# Breast
Local vs. LMA
Positioning
Pain control
ALL depends on type of surgery
More serious (reconstruction) = LMA, chagne positiongs, high pain needs
biopsy, partial mastectomy = local, supine, small pain
45
What is SLN mapping + what dyes?
Sentinel Lymph Node mapping - dye to know where cancer is
o Methylene blue = cx renal insufficiency
o Indigo carmine = cx in sulfa allergies
o Lymphazurin = rare anaphylaxis – most commonly used
46
Why might a surgeon want a short acting NMBD during breast surgery
Long thoracic nerve + wind scapula
47
# Breast
Describe tissue expander
o Plastic balloon inside where breast tissue was with sterile saline + blow up
o Low cost, no allergies, quick
48
Describe the LAT FLAP
* Latissimus Dorsi Myocutaneous (LDM)
* Below scapula
* Muscle + skin – still attached
* Cut away as pedicle graft and tunneled through axilla
* Quicker, less SE’s
49
Describ the TRAM FLAP
* Transverse Rectus Abdominus Myocutaneous (TRAM)
* From :: abdominal muscle, sub-q, skin
* Remains attached to native blood supply
* Mesh prosthesis for abdomen
50
Describe DIEP
* Deep Inferior Epigastric Perforators (DIEP)
o Skin and fat removed from abdomen (without muscle)
Very vascular, heals well, not much volume
No hernia concern
o Denervates abdomen
51
* Indications for Nissen Fundiplocation?
* What severe complications of GERD are avoided by a Niessen fundiplocation?
* Other indication?
increase lower esophageal sphincter pressure
- Stricture
- Aspiration PNA
- Esophageal Ulcerations
- Barret's Esophagus
Failure/unwilling to commit to meds
52
# Nissen Fundiplocation
How do prokinetic drugs work?
Which ones are commonly given?
- Strengthen LES & increase gastric emptying
- Metoclopramide & domperidone
53
# Nissen Fundiplocation
How do PPI's work?
Examples?
Blockade of ATPase in parietal cells - decrease acid production
"prazoles" = nexium, prilosec, protonix, prevacid
54
With Nissen Fundiplocation, pt should have documented ___________________
esophageal hyperacidity
55
What intubation technique is indicated for Niessen patients?
RSI
56
What position is indicated for Niessen Fundiplocations?
Supine, Low lithotomy, reverse Tburg
57
What piece of equipment (unique to Niessen Fundiplocations) should the CRNA be prepared to use?
Esophageal Dilator - 60 Fr
Maloney = pointy
58
What size is the esophageal dilator used for Niessen's?
60 fr
59
In what surgery is the Triangle of Calot relevant?
Cholecystectomy
60
What structures are isolated and stapled during a cholecystectomy?
- Cystic artery and hepatic duct
61
What are the indications for Cholecystectomy?
Symptomatic cholelithiasis
Symptomatic cholecystitis
62
Who is most at risk for gallbladder disease?
5 F's
- Female
- Forty
- Fair (caucasian)
- Flatulent
- Fat
63
What drugs should be considered for an emergent gallbladder?
- Prokinetics
- Bicitra
64
What position is a gallbladder placed in for surgery?
Reverse Tburg + L tilt
65
How is a sphincter of Oddi spasm treated?
Glucagon
66
When would an ERCP be indicated?
Choledocholithiasis
67
What are 4 indications for Spleenectomy?
- ITP (Immune thrombocytopenic purpura)
- Lymphoma
- Hemolytic anemia
- Trauma
68
What vaccines should have been received prior to spleenectomy?
When should they be given?
- Pneumococcal
- Meningococcal
- H. Influenza
1 week prior
69
With what pathology would one expect left lower lobe atelectasis?
Spleen problems (inflammation → swollen → pushes on LLL)
70
In what surgery would the CRNA anticipate having a type and screen or a type and cross ready?
Spleenectomy
71
Differentiate a type and screen and a type and cross. (very superficially)
- Type & Screen = blood type identified
- Type and Cross = blood type identified and bags are ready down in blood bank.
72
What position would one place a spleenectomy patient in?
- 45° right lateral decubitus
- kidney rest + table flexed
73
What are 5 indications for bowel resection?
- Ulcerative colitis
- Crohn's
- Diverticular disease
- Cancer
- Ischemic bowel
74
What is necessary pre-operatively for bowel resection patients?
- Bowel prep
- μ-opioid antagonists
- ERAS protocol
75
What would be the purpose of a μ-opioid antagonist prior to bowel surgery?
Name? When given? Why
Counteracts constipatory effects of narcotic and results in a faster resolving ileus.
ENTEREG (ALVIMOPAN) ... prior to narcotics given ... decrease ileus postop stay by 1 day
76
What is the ERAS protocol?
**Enhanced Recovery After Surgery**.
Has many components but some examples are:
- Pre-op warming
- Multimodal anesthesia - GABAPENTIN, ACETA, SCOP
- Proper hydration preoperatively - GATORADE
77
With which surgery might the CRNA more readily consider albumin vs crystalloids?
Bowel resection
78
What positions are used commonly for bowel resections?
Supine & low lithotomy
(can range all the way to very high lithotomy)
79
What is the indication for appendectomy?
Suspected appendicitis
80
Why might appendectomy patients be dehydrated?
What are the most commonly used labs to note this dehydration?
- Dehydration d/t fever & N/V
- Hemoconcentration (H/H), ↑ BUN
81
What positioning is utilized for appendectomy patients?
Supine, left arm tucked, trendelenburg (head down)
82
Which two gastric surgeries result in rapid initial weight loss?
Sleeve Gastrectomy & Gastric Bypass
83
In what gastric surgery would one expect protein and nutrient absorption to be the most affected?
Gastric Bypass
84
What is the primary adverse event associated with lap banding surgery?
Band erosion
85
Which bariatric surgery is characterized by better nutrition, easier removal, and less significant weight loss?
Lap Banding
86
What are some possible indications for Bariatric surgery?
Morbid Obesity associated with:
- HTN
- DM
- OSA
- Asthma
87
What parameters (generally) result in approval from insurance companies for bariatric surgery?
- BMI > 35 w/ comorbidities
- BMI > 40
88
What possible homeopathic remedies for appetite suppression should be considered for patients receiving bariatric surgery?
G - Supplements (gingko, green tea, etc.)
89
Prophylaxis for ____ is important for bariatric surgeries.
VTE
90
Bariatric surgery patients commonly have undiagnosed ____.
OSA
91
What position is typically used for bariatric surgeries?
- Reverse Tburg ++ Head up at 30°
92
What positioning do obese patients generally not tolerate?
Supine (or also head down)
93
What s/s is more common post lap banding surgery?
Dysphagia
94
What are some concerns for patients post-operative bariatric surgery?
- Diarrhea
- Dysphagia
- Protein malabsorption - less contact time + bile/pancreatic enzymes
- Vitamin malabsorption - A,D,E,K,B12,Ca
95
What are 6 indications for conversion of laparoscopy to laparotomy?
- Obesity
- Adhesions
- Bleeding
- Unclear anatomy
- Staple misfire
- Inability to ventilate
96
What are some indications for exploratory laparotomy?
- Trauma
- Abdominal catastrophes (ex. ischemic bowel)
- Cancer staging
97
With what surgeries would the CRNA consider an epidural placement?
Laparotomies
98
____ are necessary for the inevitable ileus in post-operative laparotomies.
NGT's
99
What surgeries are often at risk for PONV?
Gynecologic surgeries
100
What risk factors for PONV exist with gynecologic surgeries?
- Female
- Opioids
- Volatiles
- Laparoscopy/Laparotomy
101
Describe the D+C procedure
removes endometrial lining of uterues to treat bleeding from uterus or cervix
Young or old people
102
What would tend to cause bradycardia during a dilation and curettage (D&C) procedure?
Cervix manipulation via the tenaculum
103
What complications would occur with retained products of conception?
- Sepsis
- Hemorrhage
104
What positioning is utilized for both a D&C and a D&E ?
- Lithotomy
105
Which surgeries are SCIP protocol **not** indicated on?
D&C and D&E
106
What IV med may be needed in D+C and D+E ? Why?
pitocin IV
to clamp down uterus + lessen bleeding
107
What is D+E for?
Weeks preformed during?
abortion or incomplete miscarriage
20-24 wks
108
Where is oxytocin secreted from?
Neurohypophysis - posterior pituitary
109
What does oxytocin do?
- Stimulate uterine contraction
- ↑ H₂O reabsorption from glomerular filtrate
110
What is the name for synthetic oxytocin?
What is the dose?
Similar to what substance?
Pitocin
20 u/Liter
vasopressin - increase water reabs.
111
What procedure allows for examination of the endometrial cavity?
What does it investigate?
Hysteroscopy
IUB - intrauterine bleeding
112
What two fluids are used for hysteroscopy? Why?
- NS/LR
- Sorbitol
To inflate uterus with irrigating fluid
113
What equipment should be used if NS is used in a hysteroscopy?
Bipolar Cautery
*Monopolar cautery + NS = burns*
114
When should sorbitol be avoided?
With diabetic patients
causes excess fructose + sz
115
When should glycine irrigation be avoided?
Why is this?
Avoided in liver patients due to the buildup of ammonia
116
What are the two typical anesthetic options for hysteroscopy?
- Paracervical block
- General w/ LMA
117
What would most likely cause bradycardia during a hysteroscopy?
Vagal response of cervix manipulation w/ tenaculum
118
Position for Hysteroscopy? Does it require SCIP?
Lithotomy
YES SCIP abx
119
What are urethral slings used to treat?
Incontinence
Loss of support to the bladder neck + pelvic floor
120
Who is at risk of incontinence requiring a urethral sling?
- 15-60% of women
- Multiparous women (older)
- 1/4 Nulliparous young athletes - jumping sports
121
What type of anesthesia is typically performed for urethral sling patients?
What position?
General w/ LMA
Lithotomy
122
What is the sling material made of in urethral sling procedures?
Prolene mesh
123
Loss of support to the ____ ____ and the ____ ______ is responsible for incontinence in patients requiring urethral sling.
bladder neck ; pelvic floor
124
What special equipment is necessary for Condyloma removals?
- Laser masks
- Smoke evacuation system - for the "plume" - surgeon can develop condyloma
125
What is condyloma? Where do they occur?
Anesthesia? Position?
STD from HPV - oral, throat, rectal, vaginal
General (LMA) - Lithotomy
126
What causes pelvic organ (bladder, vagina, etc) prolapse?
Weakened pelvic floor
- Delivery + repair postponed
- aging
- previous pelvic surgery
127
What are the three types of prolapse?
- Cystocele (bladder) - Anterior prolapse
- Rectocele (rectum) - Posterior prolapse
- Enterocele (intestine)
128
What medical device do patients typically go home with post prolapse repair?
Foley catheter (ensures urethra won't be obstructed)
129
Anesthesia for repair procedures? Position? SCIP?
* general - ETT vs LMA
* Lithotomy
* SCIP !
* Foley catheter
130
What are the three types of hysterectomy?
* Partial hysterectomy = uterus
* Total = uterus + cervix
* BSO – Bilateral salpingo-oophorectomy = tubes + ovaries + cervix
131
What two types of cut are used in hysterectomies if an abdominal approach is indicated?
- **Pfannenstiel** (bikini cut)
- Midline
132
What is the most common surgical approach for hysterectomies?
LAVH - combination bw vaginal + belly incisions
*Laparoscopic assisted vaginal hysterectomy*
133
Hysterectomy :: anesthesia? position? abx? Special?
* GETA
* pfanneistel = supine , vaginal = lithotomy , LAVH = both
* SCIP
* foley ,, bowel prep ,, bradycardia ,, PONV
134
What was Robitics first used for?
What benefits does robotic surgery provide?
* gyn - fallopian tubal anastamoses (1999)
* 3-Dimensional Views
*Ex. Impotence rates decreased post implementation of robotic surgery for prostatectomies*
135
What are the pros and cons of robotic surgery?
- Improved dexterity
- Increased cost
- More OR time
136
What positioning is typically used with robotic surgery?
Extreme Trendelenburg + STAYING THERE !
137
Robotic surgeries necessitate less fluid administration. Why?
Positioning (severe trendelenburg) results in extreme facial and airway edema.
138
Robotic surgery - anesthesia? abx? special?
GETA
SCIP
good muscle relaxation! fluid restriction
139
140
