Exam 3- Gen. and Gyn. Surgery Flashcards
When was laparoscopy first used?
What for?
Diagnosing gynecologic conditions in the 70s
80s Lap Chole’s started
What is the purpose of gastric insufflation?
Allows for room to work inside peritoneum
What is released in body with the initial insufflation of the abdomen?
Release of catecholamines & vasopressin.
Arterial vasculature is compressed.
What is the goal pressure in mmHg for gastric insufflation?
≤ 20 mmHg
12 - 15 mmHg is most common.
What causes increased CO₂ during laparoscopic surgeries?
- Positioning (frequently Trendelenburg)
- CO₂ insufflation (absorbed by peritoneum into the blood stream).
What are the pulmonary effects of insufflation?
- ↑ PaCO₂
- ↓ compliance
- ↑ PIP
- ↓ FRC
- Atelectasis
In what laparoscopic position is atelectasis development most common?
Trendelenburg
How much change in pulmonary compliance occurs with gastric insufflation?
30 - 50% decrease in compliance
Is increased PaCO₂ in laparoscopic cases primary from diaphragm displacement or CO₂ absorption?
Primarily from diaphragm displacement.
When does the increase in PaCO₂ from gastric insufflation plateau?
10 - 15 min
How does the CRNA typically treat hypercarbia secondary to gastric insufflation?
- ↑ VT or RR
When would the CRNA be hesitant to treat a hypercarbic patient?
Towards the end of the case.
↑ CO₂ necessary to stimulate respiratory drive and facilitate extubation.
What typically causes pulmonary complications in laparoscopic cases?
Improper trocar placement
What are the pulmonary complications associated with improper trocar placement?
- SubQ emphysema, pneumothorax, pneumomediastinum
- Gas embolism
What pulmonary complication is the result of CO₂ insufflation pushing the carina upwards?
Migration of ETT from carina to the bronchus (endobronchial intubation)
What’s the hemodynamic result of a gas embolism into the vena cava?
Drop in venous return
What are the s/s of gas embolism?
- ↓ EtCO₂ (best early sign)
- ↑ HR
- Dysrhythmias
- ↓ BP w/ ↑ CVP
- Millwheel murmur (from pneumopericardium)
- Hypoxemia
What is the treatment for CO₂ gas embolism?
- Cessation of insufflation
- Trendelenburg
- Fluid bolus
- 100% O₂
- Aspiration of air
- Vasopressor support
How is endobronchial intubation detected?
- Loss of bilateral breath sounds
- ↓ pulse oximetry
At what intraperitoneal pressure do the hemodynamic effects of insufflation set in?
> 10 mmHg IAP
What hemodynamic changes are seen with insufflation?
- ↓ CO
- Reflexive ↑ BP
- Reflexive ↑ SVR
What drugs would be best for the reflexive hypertension from CO₂ insufflation?
- VA
- Nitroglycerin
- Nicardipine
- Remifentanil
Make sure it is SHORT acting
How much do cardiac arrhythmias increase with increased PaCO₂?
Trick question. Arrhythmias arise from hypoxia not from hypercarbia.
What often causes cardiac arrythmias in laparoscopic cases?
Increases in vagal tone
- Peritoneal stretch
- Pulling on cervix/fallopian tubes
- Cautery
How would the bradycardia from vagal stimulation be treated?
- Limit insufflation pressure
- Glycopyrrolate
In what position would one expect possible injury to the peroneal nerve or even compartment syndrome?
Lithotomy
What is the most common surgical complication of laparoscopy?
- Intestinal injury (perforation, common bile duct injury)
What are the possible surgical complications of laparoscopy?
- Intestinal injuries
- Vascular injuries
- Burns
- Infection
When is laparoscopy contraindicated?
Patient with ↑ ICP (tumor, trauma, etc.)
Is LMA a good option for Laparoscopic procedures?
Not really, insufflation can displace the LMA.
What are the reasons for OGT/NGT insertion in laparoscopies?
Aspiration of stomach air so surgeon has better visualization.
What important part of the SCIP protocol is anesthesia in charge of now?
Antibiotics
What are the two most common firstline antibiotics indicated by the SCIP protocol?
- Cefazolin
- Cefoxitin
What is the most common antibiotic indicated by the SCIP protocol for those with severe penicillin/cephalosporin allergy?
Vancomycin
What are the other factors important to the SCIP protocol besides antibiotics?
- β-blockers
- Temperature
- Time Out
What severe complications of GERD are avoided by a Niessen fundiplocation?
- Stricture
- Aspiration PNA
- Esophageal Ulcerations
- Barret’s Esophagus
How do prokinetic drugs work?
Which ones are commonly given?
- Strengthen LES & increase gastric emptying
- Metoclopramide & cisapride
How do PPI’s work?
Blockade of ATPase in parietal cells
What intubation technique is indicated for Niessen patients?
RSI
What position is indicated for Niessen Fundiplocations?
Supine, Low lithotomy, Head up
What piece of equipment (unique to Niessen Fundiplocations) should the CRNA be prepared to use?
Esophageal Dilator
What size is the esophageal dilator used for Niessen’s?
60 fr
In what surgery is the Triangle of Calot relevant?
Cholecystectomy
What structures are isolated and stapled during a cholecystectomy?
- Cystic artery and hepatic duct
What are the indications for Cholecystectomy?
Symptomatic cholelithiasis
Symptomatic cholecystitis
Who is most at risk for gallbladder disease?
5 F’s
- Female
- Forty
- Fair (caucasian)
- Flatulent
- Fat
What drugs should be considered for an emergent gallbladder?
- Prokinetics
- Bicitra
What position is a gallbladder placed in for surgery?
- Supine
- Head up
- Left tilt
How is a sphincter of Oddi spasm treated?
Glucagon
When would an ERCP be indicated?
Choledocholithiasis
What are indications for Spleenectomy?
- ITP (Immune thrombocytopenic purpura)
- Lymphoma
- Hemolytic anemia
- Trauma
What vaccines should have been received one week prior to spleenectomy?
- Pneumococcal
- Meningococcal
- H. Influenza
With what pathology would one expect left lower lobe atelectasis?
Spleen problems (inflammation → swollen → pushes on LLL)
In what surgery would the CRNA anticipate having a type and screen or a type and cross ready?
Spleenectomy
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.
What position would one place a spleenectomy patient in?
- 45° right lateral decubitus
What are some indications for bowel resection?
- Ulcerative colitis
- Crohn’s
- Diverticular disease
- Cancer
- Ischemic bowel
What is necessary pre-operatively for bowel resection patients?
- Bowel prep
- μ-opioid antagonists (entereg)
- ERAS protocol
What would be the purpose of a μ-opioid antagonist prior to bowel surgery?
Counteracts constipatory effects of narcotic and results in a faster resolving ileus.
Entereg (alvimopan)
What is the ERAS protocol?
Enhanced Recovery After Surgery.
Has many components but some examples are:
- Pre-op warming
- Multimodal anesthesia
- Proper hydration preoperatively
With which surgery might the CRNA more readily consider albumin vs crystalloids?
Bowel resection
What positions are used commonly for bowel resections?
Supine & low lithotomy
(can range all the way to very high lithotomy)
What is the indication for appendectomy?
Suspected appendicitis
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
What positioning is utilized for appendectomy patients?
Supine, left arm tucked, trendelenburg (head down)
Which two gastric surgeries result in rapid initial weight loss?
Sleeve Gastrectomy & Gastric Bypass
In what gastric surgery would one expect protein and nutrient absorption to be the most affected?
Gastric Bypass
What is the primary adverse event associated with lap banding surgery?
Band erosion
Which bariatric surgery is characterized by better nutrition, easier removal, and less significant weight loss?
Lap Banding
What are some possible indications for Bariatric surgery?
Morbid Obesity associated with:
- HTN
- DM
- OSA
- Asthma
What parameters (generally) result in approval from insurance companies for bariatric surgery?
- BMI > 35 w/ comorbidities
- BMI > 40
What possible homeopathic remedies for appetite suppression should be considered for patients receiving bariatric surgery?
G - Supplements (gingko, green tea, etc.)
Prophylaxis for ____ is important for bariatric surgeries.
VTE
Bariatric surgery patients commonly have undiagnosed ____.
OSA
What position is typically used for bariatric surgeries?
- Head up at 30°
What positioning do obese patients generally not tolerate?
Supine (or also head down)
What s/s is more common post lap banding surgery?
Dysphagia
What are some concerns for patients post-operative bariatric surgery?
- Diarrhea
- Dysphagia
- Protein malabsorption
- Vitamin malabsorption
What are some indications for conversion of laparoscopy to laparotomy?
- Obesity
- Adhesions
- Bleeding
- Unclear anatomy
- Staple misfire
- Inability to ventilate
What are some indications for exploratory laparotomy?
- Trauma
- Abdominal catastrophes (ex. ischemic bowel)
- Cancer staging
With what surgeries would the CRNA consider an epidural placement?
Laparotomies
____ are necessary for the inevitable ileus in post-operative laparotomies.
NGT’s
What surgeries are often at risk for PONV?
Gynecologic surgeries
What risk factors for PONV exist with gynecologic surgeries?
- Female
- Opioids
- VAA’s
What would tend to cause bradycardia during a dilation and curettage (D&C) procedure?
Cervix manipulation via the tenaculum
What complications should the CRNA consider post D&C ?
- Sepsis
- Hemorrhage
What positioning is utilized for both a D&C and a D&E ?
- Lithotomy
Which surgeries are SCIP protocol not indicated on?
D&C and D&E
Where is oxytocin secreted from?
Neurohypophysis
Posterior Pituatary Gland
What does oxytocin do?
- Stimulate uterine contraction
- ↑ H₂O reabsorption from glomerular filtrate
What is the name for synthetic oxytocin?
Pitocin
What procedure allows for examination of the endometrial cavity?
Hysteroscopy
What two fluids are used for hysteroscopy?
- NS
- Sorbitol
What equipment should be used if NS is used in a hysteroscopy?
Bipolar Cautery
Monopolar cautery + NS = burns
When should sorbitol be avoided?
With diabetic patients
When should glycine irrigation be avoided?
Why is this?
Avoided in liver patients due to the buildup of ammonia
What are the two typical anesthetic options for hysteroscopy?
- Paracervical block
- General w/ LMA
What would most likely cause bradycardia during a hysteroscopy?
Vagal response of cervix manipulation w/ tenaculum
What are urethral slings used to treat?
Incontinence
Who is at risk of incontinence requiring a urethral sling?
- Multiparous women (older)
- Nulliparous young athletes
What type of anesthesia is typically performed for urethral sling patients?
General w/ LMA
What is the sling material made of in urethral sling procedures?
Prolene mesh
Loss of support to the ____ ____ and the ____ ______ is responsible for incontinence in patients requiring urethral sling.
bladder neck ; pelvic floor
What equipment is necessary for Condyloma removals?
AKA Genital Warts
- Laser masks
- Smoke evacuation system
What causes pelvic organ (bladder, vagina, etc) prolapse?
Weakened pelvic floor
What are the three types of prolapse discussed in lecture?
- Cystocele (bladder)
- Rectocele (rectum)
- Enterocele (intestine)
What medical device do patients typically go home with post prolapse repair?
Foley catheter (ensures urethra won’t be obstructed)
What are the three types of hysterectomy?
* Partial= Uterus
* Total= Cervix and uterus (w/wo fallopian tubes)
What two types of cut are used in hysterectomies if an abdominal approach is indicated?
- Pfannenstiel (bikini cut)
- Midline
What is the most common surgical approach for hysterectomies?
LAVH
Laparoscopic assisted vaginal hysterectomy
What benefits does robotic surgery provide?
Increased safety profile
Ex. Impotence rates decreased post implementation of robotic surgery for prostatectomies
What are the pros and cons of robotic surgery?
- Improved dexterity
- Increased cost & OR time
What positioning is typically used with robotic surgery?
Extreme Trendelenburg
Robotic surgeries necessitate less fluid administration. Why?
Positioning (severe trendelenburg) results in extreme facial and airway edema.
