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’s the risk when giving lymphazurin for SLN mapping?
A. causes renal damage
B. rare anaphylaxis
C. not for those w/ sulfa allergy
D. causes liver failure
B. rare anaphylaxis
What is the contraindication for using indigo carmine for SLN mapping?
sulfa allergy
What can be done for pain control in breast procedures? Select 2
A. long acting narcotics for biopsies
B. multimodal
C. paravertebral block
D. short acting narcotics for reconstruction
B. multimodal
C. paravertebral (thoracic) block
The continued use of NMBD during breast procedures (specifically mastectomies) is dependent on:
A. lymph node removal
B. how frequent repositioning will occur
C. surgeon preference to test for long thoracic nerve injury
D. whether wire localization was used or not
c. surgeon preference to test long thoracic nerve periodically and make sure it wasn’t injured during procedure
per Dr. Kane
What are 4 options for breast reconstruction?
- tissue expander
- Latissimus dorsi myocutaneous (LDM) - below scapula, muscle and skin, cut away as a pedicle graft and tunnel thru axilla, pull out thru the front where breast would be
- Transverse rectus abdominus myocutaneous (TRAM) - abdominal muscle, subq, and skin is used to recreate breast…requires a mesh prosthesis to abdomen to prevent hernia!
- deep inferior epigastric perforators (DIEP) - denervates abdomen
T/F: DIEP remove skin, fat and muscle from abdomen for breast reconstruction.
FALSE - Deep inferior epigastric perforators (DIEP) removes skin and fat from abdomen without removing muscle.
DIEP denervates abdomen tho
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 drugs would you give preoperatively for a nissen fundoplication? select 2.
A. nexium
B. famotidine
C. reglan
D. zantac
A. Nexium (esomeprazole - a PPI)
C. Reglan (metoclopramide - a prokinetic)
For a nissen fundoplication, what should be documented preoperatively?
A. use of antacids at home
B. esophageal hyperacidity
C. frequency of reflux
D. if pt is unwilling to commit to medication
B. esophageal hyperacidity
For nissen fundoplication:
List PPIs
“-prazoles”
* esomeprazole (Nexium)
* lansoprazole (Prevacid)
* pantoprazole (Protonix)
* omeprazole (Prilosec)
For Nissen fundoplication:
What are the 2 prokinetic drugs to give preop? Why are they beneficial?
metoclopramide (Reglan)
domperidone (Motilium)
* to strengthen LES and increase gastric emptying
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 are the 2 indications for cholecystectomy?
- Symptomatic cholelithiasis
- Symptomatic cholecystitis
what are the 5 F’s?
those usually needing chole’s
female, forty, fair, flatulent, fat
What drugs would you give preoperatively for a lap chole? Select 2.
A. famotidine
B. reglan
C. bicitra
D. glucagon
B. Prokinetics (metoclopramide/Reglan)
C. Bicitra (sodium citrate - to neutralize stomach acid)
Many emergent so consider them Full stomachs!
Since a lap cholecystectomy is usually emergent and likely “full stomachs,” what are 2 intraoperative considerations?
A. skip the antibiotics
B. NGT
C. GETA
D. OGT
E. do not give any opioids
F. do multimodal approach using paravertebral block
C. GETA (secure airway)
D. OGT (decompress belly to decrease aspiration risk)
What is the positioning for cholecystectomy?
Supine, reverse Tburg, left tilt
Other intraop considerations:
* SCIP antibiotics
* may require Intra-Op Cholangiogram (Sphincter of Oddi spasm = give Glucagon)
* May require ERCP for choledocholithiasis
indications for splenectomy
- ITP
- Lymphoma
- Hemolytic anemia
- Trauma
What are 2 specific preop considerations for splenectomy?
A. vaccines immediately post op
B. vaccines 1 week preop
C. need 2 antibiotics
D. can do local or regional instead of GETA
E. eval LLL atelectasis
B. Should have received pneumococcal, meningococcal, and H influenza vaccinations 1 week preop
E. Evaluate LLL atelectasis
What intraop considerations are specifically important for a splenectomy? select 2.
A. LMA is preferred
B. type and cross
C. left lateral decubitus position
D. extra IV access
B. Type and cross (preferred over a t&screen)
D. Xtra venous access (18G preferrably)
also:
* GETA
* Position (45 degree right lateral decubitus; Kidney rest, table flexed)
* SCIP antibiotics
indications for bowel resection
- Ulcerative colitis
- Crohn’s disease
- Diverticular disease
- Cancers
- Ischemic bowel
What are some preop considerations for bowel resection? Select 3.
A. no tylenol preop for these patients
B. bowel prep
C. keep npo after midnight
D. give entereg before giving narcotics
E. preoperative warming
F. cannot perform procedure on patients with afib
B. Bowel prep
D. Mu-opioid antagonists: Entereg (alvimopan)
E. ERAS (Preop warming; multimodal with Gabapentin, acetaminophen, scopolamine; and ALLOW Gatorade up to 2 hrs before surgery so they’re not super dry or hypoglycemic)
What are some intraop considerations specific to bowel resections? Select 2
A. consider giving albumin b/c lots of fluid shifts will occur
B. NGT preferred since most likely will remain npo after procedure
C. minimal aspiration risk
D. do not require antibiotics given within 1 hr
A. Consider albumin vs crystalloid
B. NGT > OGT
Others:
* GETA (Consider full stomach/aspiration risk?)
* Position: Supine or low lithotomy
* SCIP antibiotics
* Postop pain control
What is the main indication for appendectomy
suspected appendicitis (usually emergent)
What are preop considerations for appendectomies? Select 2.
A. consider full stomach
B. should cancel procedure if patient has a fever
C. no preop meds required for this procedure
D. most likely dehydrated
A. consider full stomach b/c usually emergent! (GETA/RSI/OGT)
D. may be dehydrated d/t fever and N/V
so will see hemoconcentration (elevated BUN w/ normal creat)
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
indications for bariatric surgery
morbid obesity assoc w htn, dm, OSA, asthma
BMI > 35 w assoc comorbidities
BMI > 40
What are some preop considerations for bariatric surgery? select 2.
A. can use an LMA
B. allow gatorade up to 2 hrs before surgery
C. may be on appetite suppressants
D. limit preop sedation
E. don’t give any VTE prophylaxis
C. Review medication list - may be on appetite suppressors
D. Assess airway - limit preoperative sedation since they will likely desat quickly or commonly have undiagnosed OSA
Also:
* VTE prophylaxis is critical!!!!
What are intraoperative considerations for bariactric surgery? Select 3.
A. lap bands are not easily reversible
B. reverse Tburg
C. good preoxygenation/denitrogenation
D. remove OGT before stapling
E. obese pts tolerate supine better than upright
F. gastric bypass comes will less risk/complications
B. Reverse Tburg/HOB up 30 degrees…..
C. GOOD pre-oxygenation + GETA/RSI!! (obese patients do NOT tolerate supine position)
D. remove OGT before stomach stapled
also:
* Calibration tube/methylene blue
what are the 2 main long term concerns for bariatric sx?
A. constipation
B. dysphasia
C. recurrent cardiac arrythmias
D. vitamin malabsorption
E. protein malabsorption
D. Vitamin malabsorption (A, D, E, K, B12, calcium)
E. Protein malabsorption (less contact time, less bile/pancreatic enzymes)
other 2 long term concerns: dysphaGia and diarrhea
what are indications that would convert a laproscopic procedure into a laparotomy?
- Obesity
- Adhesions
- Bleeding
- Unclear anatomy
- Staple misfire
- Inability to ventilate
3 indications for an exploratory laparotomy:
A. dysphagia
B. inability to ventilate
C. trauma
D. obesity
E. abd catastrophes (gunshot wounds)
F. staging
C. trauma
E. abd catastrophies
F. staging
What are some intraop considerations for an exploratory laporotomy? select 2
A. could just do local
B. profound muscle relaxation
C. NGT
D. keep warm
E. all but A
E. all but A
entire list:
* GETA!!
* Profound muscle relaxation
* NGT
* Consider epidural placement
* Consider multi-modal pain control
* Keep warm!!!
What are 4 risk factors for PONV?
female, laparoscopy or laparotomy, opioids, volatiles
What is an intraop considerations for D&C (dilation & curettage) that we haven’t seen with any of the other laparoscopic procedures?
A. lithotomy positioning
B. OGT required
C. no SCIP antibiotics
D. no RSI
C. No SCIP antibiotics required (unless obviously septic)
Entire list:
* Lithotomy (stirrups): Peroneal nerve injury & Table
* General anesthesia
* May be combined with other procedures (hysteroscopy, conization)
* May need Pitocin IV
* May have bradycardia
How much pitocin do we put in a bag for infusion?
20 units / liter
per dr kane, should be at least 500 mL to 1L bag
Fill in the blanks:
Pitocin IV is synthetic oxytocin. Oxytocin is secreted from ___ and stimulates uterine contraction to ___.
A. adeno-hypophysis; stop bleeding.
B. neuro-hypophysis; stop bleeding.
C. adrenal cortex; stop bleeding.
D. adeno-hypophysis; increase water reabsorption
E. neuro-hypophysis; increase water reabsorption.
B. neuro-hypophysis; stop bleeding.
Oxytocin is secreted from neuro-hypophysis and stimulates uterine contraction to stop bleeding. Pitocin IV may be given during D&C and/or D&E.
During a hysteroscopy, the surgeon must inflate the uterus to get the scope in using NS, LR, or sorbitol. What is important to rmbr about choosing a fluid?
A. NS runs a risk of hyperkalemia
B. Sorbitol is hypotonic so could cause volume overload/pulm edema
C. LR has a risk of electrical current.
D. choosing a fluid is not as important as dilating the cervix.
B. Sorbitol is a hypotonic solution so can cause vol overload/pulm edema
* sorbitol is a sugar alcohol and has less electrolytes than NS or LR
* NS runs risk of electrical current because of Na+
* LR has a risk of hyperkalemia since more K+ in it than in NS
kept this card from last year’s class
What pts may require urethral slings? What is this sling procedure even for? Select 2
A. older, multiparous women
B. young, multiparous women
C. woman with a missed abortion
D. to repair abdominal hernia
E. for stress urinary incontinence
F. to repair a cystocele
A. older, multiparous women (1/4 are nulliparious, college athletes)
E. indicated for stress urinary incontinence (from loss of support to bladder neck and pelvic floor)
What is a specific intraoperative consideration for condyloma?
A. no lithotomy
B. must have laser masks
C. can be local or GETA
D. need prolene mesh
B. Laser masks are a must b/c this is a laser evacuation procedure!
also need Smoke evacuation
Gynecological procedures:
what are the 3 types of repairs?
hint: the -cele’s
cystocele - anterior (bladder) prolapse
rectocele - posterior (rectum) prolapse
enterocele - small bowel prolapse
caused by weakened pelvic floor
What are some intraop considerations for hysterectomy/BSO (bilateral salpingo-oophorectomy)?
- Position???
- General anesthesia
- Foley catheter
- SCIP
- Bowel prep??
- Bradycardia??
- PONV??
An intraoperative consideration specific to robotic surgery includes:
A. foley catheter
B. fluid restriction
C. less NMBD
D. SCIP
B. Fluid restriction!!!
Also:
* General anesthesia
* Positioning and staying there!!!
* SCIP antibiotics
* Good muscle relaxation
