E3 - General/Lap/Gynecologic Flashcards
Creating a pneumoperitoneum (aka Intraperitoneal insufflation of CO2) allows the surgeon to: Select 2.
A. decrease intraabd pressure
B. identify intraperitoneal space
C. to cause hypercapnea
D. have room to work
B. identify intraperitoneal space
D. room to work
What occurs systemically at the onset of pneumoperitoneum?
A. inhibition of epi and norepi release causing bradycardia
B. decreased CO2 levels in blood
C. release of catecholamines and vasopressin
D. sharp increase of IAP to 25 mmHg
C. Release of catecholamines and vasopressin at onset of pneumoperitoneum
also: Compression of arterial vasculature occurs
What is the ideal intraabdominal pressure (IAP) when creating a pneumoperitoneum?
</= 20 mmHg
preferred 12-15 mmHg
Creating a pneumoperitoneuum causes increased intraabdominal pressure. What pulmonary effects are expected?
A. decreased PIP and decreased FRC
B. decreased PIP and increased FRC
C. increased PIP and decreased FRC
D. increased PIP and increased FRC
C. increased PIP and decreased FRC which can lead to development of atelectasis
Entire List:
* Decreased compliance 30-50%
* Increased PIP
* Decreased FRC
* Development of atelectasis
what is the main treatment for increased PaCO2 caused by insufflation?
increase Vm
by either increasing Vt or RR or both
what would you do for an elevated ETCO2 early in the case vs late in the case?
leave ETCO2 somewhat on the higher side if its toward end of case to allow the pt’s hypercarbic drive to breathe
What pulmonary complications can occur with insufflation? select 2.
A. subq emphysema
B. hemothorax
C. fat embolism
D. endobronchial intubation
A. Subq-emphysema/ pneumothorax/ pneumomediastinum
D. Endobronchial intubation (aka right main stemming)
also:
* Gas embolism
If the patient is suspected of having a gas embolism from insufflation, what diagnostic criteria would you see on the monitor? Select 3
A. hypertension
B. decreased ETCO2
C. bradycardia
D. tachycardia
E. hypotension
F. increased ETCO2
B. decreased ETCO2
D. tachycardia
E. hypotension w/ increased CVP
other dx criteria:
* cardiac dysrhythmias
* hypoxemia
* millwheel murmur (swooshing water sound)
What is the treatment for a gas embolism caused by insufflation?
A. fluid bolus and stop insufflating
B. give vasodilating agent
C. ask surgeon to close and prone the patient
D. reverse trendelenberg
A. fluid bolus and stop insufflation or release of pneumoperitoneum
Also:
* put pt in Trendelenberg (head down) and left lateral (to trap air bubble in right atria), give 100% O2, aspirate air, and vasopressors!!!
Fill in the blank
Insufflation has begun. Diaphragm has now __ and caused __ displacement of carina.
A. elevated; caudad
B. lowered; cephalad
C. elevated; cephalad
D. lowered; caudad
C. elevated; cephalad (towards head)
watch for ETT moving into right main stem bronchus
ETT has now gone right main stem after insufflation. What do you do?
A. adjust ETT
B. check for bilateral breath sounds
C. assess pulse ox
D. all of the above
D. all of the above
During insufflation, at what intraabdominal pressure do we see hemodynamic changes occur?
> 10mmHg IAP
What are the hemodynamic effects of insufflation? Select 2
A. decreased SVR
B. increased HR
C. decreased CO
D. increased SVR
C. Decreased CO (proportional)
D. Increased SVR/PVR and Increased arterial pressure
Resolves in several minutes
What is a treatment for increased SVR and arterial pressure caused by insufflation?
A. vaporub
B. nitroglycerin
C. vasopressor support
D. hydralazine
B. Nitroglycerin
can also give:
* Vapor/volatiles
* Nicardipine (Cardene)
* Remifentanil
* esmolol (super quick)
basically any short-acting vasodilators
T/F: Cardiac arryhthmias during insufflation are from reflex increases in vagal tone from peritoneal stretch, NOT from high levels of PaCO2.
“cardiac arrythmias” = as in, extreme bradycardia leading to asystole
True.
Cardiac arrythmias do not correlate with level of PaCO2.
Bradycardia or even asystole are caused by:
* reflex increases in vagal tone from Peritoneal stretch and Electrocautery/stretch of fallopian tubes
limit insufflation pressures and GIVE GLYCOPYRROLATE (robinul)
whats the tx for bradycardia seen with insufflation?
glycopyrrolate (Robinol) and limit insufflation pressures!
what changes occur with reverse trendelenburg position? Select 2.
A. decreased CO
B. increased CO
C. easier to ventilate
D. harder to ventilate
A. Decreased CO
C. easier to (favorable) ventilate!
and venous stasis so put SCDs on
what changes occur with trendelenburg position?
should be review from last exam..
- Facial/pharyngeal/laryngeal airway edema
- increased CVP/CO
- increased intraocular pressure
- Altered pulmonary mechanics…FRC, TLV, compliance
What are the common nerve injuries with general/lap/lithotomy position? Select 3 choices.
A. brachial plexus
B. common peroneal nerve
C. ulnar nerve
D. obturator and femoral nerve
E. sciatic nerve
F. axillary nerve
A. brachial plexus (from overextension of arm)
B. common peroneal nerve (from stirrups in lithotomy)
D. obturator and femoral nerve (from hip flexion)
risk of compartment syndrome!!
why is laparoscopy usually chosen over laparotomy?
A. less chance of infection
B. no pulm dysfunction
C. decreases PONV
D. slower recovery
C. Decreases postop nausea/vomiting and post op pain!!
Also: Less pulmonary dysfunction (but not none)
The most common surgical complication of laparoscopy is:
A. vascular injuries
B. infection
C. intestinal injuries
D. burns
E. retroperitoneal hematomas
C. Intestinal injuries: perforations, Common Bile Duct injury (30-50% of serious complications and May remain undiagnosed)
Others:
* Vascular injuries: Retroperitoneal hematomas often insidious, Great vessel injury emergent
* Burns: 15-20% of complications
* Infection: very small
Laparoscopy procedures are contraindicated in patients with:
A. spleen laceration
B. hydrocephalus
C. liver failure
D. chronic kidney disease
Contraindicated in increased ICP - so pts with a brain tumor, head trauma, or B. hydrocephalus
unless emergent situation and needing to do perform procedure to save the pt’s life
Besides preop meds, narcotics, NMBD, and positioning, some important anesthesia considerations for laparoscopy include:
A. use of methylene blue
B. neuraxial anesthesia
C. GETA and controlled ventilation
D. conscious sedation
C. GETA (ETT > LMA) and Controlled ventilation (keep normal ETCO2 by adjusting volume vs RR)
Also consider:
* OGT mainly!!
* IVF for hemodynamic changes (Young -crystalloids .. vs elderly - albumin esp if dehydrated)
What are some postop considerations for laparoscopy? select 2.
A. o2 should not be for everyone
B. be ready to give more than just zofran for PONV prevention
C. treat shoulder pain that most likely is referred pain
D. cannot provide o2 in some PACUs
C. PONV prevention (zofran, decadron, scopalamine)
D. tx of surgical or referred pain (discuss referred pain preop!! that they may wake up w/ shoulder pain!)
Discuss referred pain preop
What 4 things entail the Surgical Care Improvement Project?
hint: ABTT
- ABX: within 1 hr
- BB (if already on one at home): within 24 hrs
- temp: =/> 36 C (especially bowel cases wanna be >36 C)
- time out: prior to incision
abx for gyn procedures: 1-2 G of cefazolin (most likely)
What are the 5 types of breast procedures?
- Biopsy: excision of breast lesion with margins
- Lumpectomy: partial mastectomy (lesion 2.5-5cm)
- Simple mastectomy: breast and nipple (No lymph node involvement or poor surgical risk)
- Modified radical (little bit drastic): breast, nipple, axillary lymph nodes (+/- reconstruction)
- Radical (super drastic) mastectomy: entire breast, nodes, pectoralis muscle
What is a specific preop consideration for breast procedures?
A. biopsies are only under GETA
B. get a pregnancy test
C. no antibiotics prior
D. cancel if radiation/chemo prior
B. Pregnancy tests
And other considerations:
* Preop meds
* SCIP antibiotics
* Evaluation of cardio/pulm if radiation/chemo given prior
Regarding positioning during a breast procedure, what is important to consider for biopsy vs reconstruction?
A. biopsy will be done in sitting position
B. can use LMA for reconstruction since procedure won’t require much repositioning
C. excision will require more repositioning
D. use GETA for reconstruction since there will likely be a lot repositioning
D. use GETA for reconstruction sx since a lot of repositioning may occur
local and/or LMA for biopsy since mainly will just be supine and simple
What 3 dyes are used for sentinel lymph node mapping?
A. isosulphan blue
B. pink chlorhexadine
C. methylene blue
D. lymphazurin
E. indocyanine green
F. indigo carmine
C. methylene blue
D. lymphazurin
F. indigo carmine
what’s the contraindication for using methylene blue during SLN mapping?
chronic renal insufficiency
What is the indication for nissen fundoplication?
A. weight loss
B. increase LES pressure
C. symptomatic cholecystitis
D. repair esophageal ulcerations
B. increase lower esophageal sphincter pressure which will help reduce GERD symptoms and complications!
* low LES pressure is caused by complications of GERD or from failure or unwillingness to commit to meds
What are some intraop considerations for nissen fundoplication? Select 2.
A. always RSI
B. OGT instead of NGT
C. prone position
D. no antibiotics for this procedure
A. always GETA/RSI
B. OGT
also:
* Preop meds
* SCIP antibiotics
* Position: Supine, low lithotomy, reverse Tburg (see picture)
* Esophageal dilator (60 fr)
what’s a specific consideration for a nissen fundoplication?
A. 3 antibiotics for this procedure
B. use NGT
C. can’t perform on barrett’s esophagus
D. use of an esophageal dilator
D. esophageal dilator (60 Fr) - used as a sizer to keep esophagus from being squeezed tighter/more closed than it should be
What is a specific positioning consideration for appendectomy?
A. prone
B. tuck left arm
C. support c spine
D. reverse trendelenberg
B. supine, left arm tucked; trendelenberg
Other considerations:
* SCIP abx
* geta (consider full stomach b/c usually emergency) + OGT
Compare the 3 bariatric surgeries
- sleeve gastrectomy: only 1 suture line, safer and rapid initial wt loss
- lap banding: no suture line but band erosion, slow weight loss, easily reversible
- gastric bypass: 2 suture lines, rapid initial wt loss, malabsorption/nutrients affected
