Exam 3- Gen. and Gyn. Surgery Flashcards
1
Q
When was laparoscopy first used?
What for?
A
Diagnosing gynecologic conditions in the 70s
80s Lap Chole’s started
2
Q
What is the purpose of gastric insufflation?
A
Allows for room to work inside peritoneum
3
Q
What is released in body with the initial insufflation of the abdomen?
A
Release of catecholamines & vasopressin.
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
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
- ↓ FRC
- ↓ compliance
- ↑ PIP
- ↑ PaCO₂
- Atelectasis
7
Q
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
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
10 - 15 min
11
Q
How does the CRNA typically treat hypercarbia secondary to gastric insufflation?
A
- ↑ 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 respiratory drive and facilitate extubation.
13
Q
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, pneumomediastinum
- Gas embolism
- Endobronchial intubation
15
Q
What pulmonary complication is the result of CO₂ insufflation pushing the carina upwards?
A
Migration of ETT from carina to the bronchus (endobronchial intubation)
16
Q
What’s the hemodynamic result of a gas embolism into the vena cava?
A
Drop in venous return
17
Q
What are the s/s of gas embolism?
A
- ↓ EtCO₂ (best early sign)
- ↑ HR
- ↓ BP w/ ↑ CVP
- Hypoxemia
- Dysrhythmias
- Millwheel murmur (from pneumopericardium)
18
Q
What is the treatment for CO₂ gas embolism?
A
- Cessation of insufflation
- Trendelenburg
- Fluid bolus
- 100% O₂
- Aspiration of air
- Vasopressor support
19
Q
How is endobronchial intubation detected?
A
- Loss of bilateral breath sounds
- ↓ pulse oximetry
20
Q
At what intraperitoneal pressure do the hemodynamic effects of insufflation set in?
A
> 10 mmHg IAP
21
Q
What hemodynamic changes are seen with insufflation? At what IAP does it occur?
A
- ↓ CO
- Reflexive ↑ BP
- Reflexive ↑ SVR
- > 10 mmHg
22
Q
What drugs would be best for the reflexive hypertension from CO₂ insufflation?
A
- VA
- Remifentanil
- Nitroglycerin
- Nicardipine
Make sure it is SHORT acting
23
Q
How much do cardiac arrhythmias increase with increased PaCO₂?
A
Trick question. Arrhythmias arise from hypoxia not from hypercarbia.
24
Q
What often causes cardiac arrythmias in laparoscopic cases?
A
Increases in vagal tone
- Peritoneal stretch
- Pulling on cervix/fallopian tubes
- Cautery
25
How would the bradycardia from vagal stimulation be treated?
- Limit insufflation pressure
- Glycopyrrolate
26
In what position would one expect possible injury to the peroneal nerve or even compartment syndrome?
Lithotomy
27
What is the most common surgical complication of laparoscopy?
- Intestinal injury (perforation, common bile duct injury)
28
What are the possible surgical complications of laparoscopy?
- Intestinal injuries
- Vascular injuries
- Burns
- Infection
29
When is laparoscopy contraindicated?
Patient with ↑ ICP (tumor, trauma, etc.; ↑ CO2 absorption = ↑ ICP)
30
Is LMA a good option for Laparoscopic procedures?
Not really, insufflation can displace the LMA.
31
What are the reasons for OGT/NGT insertion in laparoscopies?
Aspiration of stomach air so surgeon has better visualization.
32
What important part of the SCIP protocol is anesthesia in charge of now?
Antibiotics
33
What are the two most common firstline antibiotics indicated by the SCIP protocol?
- Cefazolin
- Cefoxitin
34
What is the most common antibiotic indicated by the SCIP protocol for those with severe penicillin/cephalosporin allergy?
Vancomycin
35
What are the other factors important to the SCIP protocol besides antibiotics?
- β-blockers
- Temperature
- Time Out
36
What is the indication for a Nissen fundoplication?
What severe complications of GERD are avoided by a Nissen fundoplication?
Increase lower esophageal sphincter pressure (GERD)
GERD complications:
- Stricture
- Aspiration PNA
- Esophageal Ulcerations
- Barret's Esophagus
37
How do prokinetic drugs work?
Which ones are commonly given?
- Strengthen LES & increase gastric emptying
- Metoclopramide & domperidone
38
How do PPI's work?
Blockade of hydrogen-potassium ATPase pump in parietal cells
39
What intubation technique is indicated for Niessen patients?
RSI
40
What position is indicated for Niessen Fundiplocations?
Supine, Low lithotomy, Head up
41
What piece of equipment (unique to Niessen Fundiplocations) should the CRNA be prepared to use?
Esophageal Dilator
42
What size is the esophageal dilator used for Niessen's?
60 fr
43
In what surgery is the Triangle of Calot relevant?
Cholecystectomy
44
What structures are isolated and stapled during a cholecystectomy?
- Cystic artery and hepatic duct
45
What are the indications for Cholecystectomy?
Symptomatic cholelithiasis
Symptomatic cholecystitis
46
Who is most at risk for gallbladder disease?
5 F's
- Female
- Forty
- Fair (caucasian)
- Flatulent
- Fat
47
What GI drugs should be considered for an emergent gallbladder?
- Prokinetics
- Bicitra
48
What position is a gallbladder placed in for surgery?
- Supine
- Head up
- Left tilt
49
How is a sphincter of Oddi spasm treated?
Glucagon
50
When would an ERCP be indicated?
Choledocholithiasis
51
What are indications for Spleenectomy?
- ITP (Immune thrombocytopenic purpura)
- Lymphoma
- Hemolytic anemia
- Trauma
52
What vaccines should have been received one week prior to spleenectomy?
- Pneumococcal
- Meningococcal
- H. Influenza
53
With what pathology would one expect left lower lobe atelectasis?
Spleen problems (inflammation → swollen → pushes on LLL)
54
In what surgery would the CRNA anticipate having a type and screen or a type and cross ready?
Spleenectomy
55
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.
56
What position would one place a spleenectomy patient in?
- 45° right lateral decubitus
57
What are some indications for bowel resection?
- Ulcerative colitis
- Crohn's
- Diverticular disease
- Cancer
- Ischemic bowel
58
What is necessary pre-operatively for bowel resection patients?
- Bowel prep
- μ-opioid antagonists (entereg)
- ERAS protocol
59
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)
60
What is the ERAS protocol?
**Enhanced Recovery After Surgery**.
Has many components but some examples are:
- Pre-op warming
- Multimodal anesthesia (Gabapentin, tylenol, scopolamine)
- Proper hydration preoperatively
61
With which surgery might the CRNA more readily consider albumin vs crystalloids?
Bowel resection
62
What positions are used commonly for bowel resections?
Supine or low lithotomy
(can range all the way to very high lithotomy)
63
What is the indication for appendectomy?
Suspected appendicitis
64
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
65
What positioning is utilized for appendectomy patients?
Supine, left arm tucked, trendelenburg (head down)
66
Which two gastric surgeries result in rapid initial weight loss?
Sleeve Gastrectomy & Gastric Bypass
67
In what gastric surgery would one expect protein and nutrient absorption to be the most affected?
Gastric Bypass
68
What is the primary adverse event associated with lap banding surgery?
Band erosion
69
Which bariatric surgery is characterized by better nutrition, easier removal, and less significant weight loss?
Lap Banding
70
What are some possible indications for Bariatric surgery?
Morbid Obesity associated with:
- HTN
- DM
- OSA
- Asthma
71
What parameters (generally) result in approval from insurance companies for bariatric surgery?
- BMI > 35 w/ comorbidities
- BMI > 40
72
What possible homeopathic remedies for appetite suppression (used at home) should be considered for patients receiving bariatric surgery?
G - Supplements (gingko, green tea, etc.)
73
Prophylaxis for ____ is important for bariatric surgeries.
VTE
74
Bariatric surgery patients commonly have undiagnosed ____.
OSA
75
What position is typically used for bariatric surgeries?
- R. Trendelengurg/Head up at 30°
76
What positioning do obese patients generally not tolerate?
Supine (or also head down)
77
What s/s is more common post lap banding surgery?
Dysphagia
78
What are some concerns for patients post-operative bariatric surgery?
- Diarrhea
- Dysphagia
- Protein malabsorption
- Vitamin malabsorption
79
What are some indications for conversion of laparoscopy to laparotomy?
- Obesity
- Adhesions
- Bleeding
- Unclear anatomy
- Staple misfire
- Inability to ventilate
80
What are some indications for exploratory laparotomy?
- Trauma
- Abdominal catastrophes (ex. ischemic bowel)
- Cancer staging
81
With what surgeries would the CRNA consider an epidural placement?
Laparotomies
82
____ are necessary for the inevitable ileus in post-operative laparotomies.
NGT's
83
What surgeries are often at risk for PONV?
Gynecologic surgeries
84
What risk factors for PONV exist with gynecologic surgeries?
- Female
- Laparotomy or laparoscopy
- Opioids
- Volatile anesthetics
85
What would tend to cause bradycardia during a dilation and curettage (D&C) procedure?
Cervix manipulation via the tenaculum
86
What complications should the CRNA consider post D&C ?
- Sepsis
- Hemorrhage
87
What positioning is utilized for both a D&C and a D&E ?
- Lithotomy
88
Which surgeries are SCIP protocol **not** indicated on?
D&C and D&E
89
Where is oxytocin secreted from?
Neurohypophysis
| Posterior Pituatary Gland
90
What does oxytocin do?
- Stimulate uterine contraction
- ↑ H₂O reabsorption from glomerular filtrate
91
What is the name for synthetic oxytocin?
Pitocin
92
What procedure allows for examination of the endometrial cavity?
Hysteroscopy
93
What two fluids are used for hysteroscopy?
- NS
- Sorbitol
94
What equipment should be used if NS is used in a hysteroscopy?
Bipolar Cautery
*Monopolar cautery + NS = burns*
95
When should sorbitol be avoided?
With diabetic patients
96
When should glycine irrigation be avoided?
Why is this?
Avoided in liver patients due to the buildup of ammonia
97
What are the two typical anesthetic options for hysteroscopy?
- Paracervical block
- General w/ LMA
98
What would most likely cause bradycardia during a hysteroscopy?
Vagal response of cervix manipulation w/ tenaculum
99
What are urethral slings used to treat?
Incontinence
100
Who is at risk of incontinence requiring a urethral sling?
- Multiparous women (older)
- Nulliparous young athletes
101
What type of anesthesia is typically performed for urethral sling patients?
General w/ LMA
102
What is the sling material made of in urethral sling procedures?
Prolene mesh
103
Loss of support to the ____ ____ and the ____ ______ is responsible for incontinence in patients requiring urethral sling.
bladder neck ; pelvic floor
104
What equipment is necessary for Condyloma removals?
| AKA Genital Warts
- Laser masks
- Smoke evacuation system
105
What causes pelvic organ (bladder, vagina, etc) prolapse?
Weakened pelvic floor
106
What are the three types of prolapse discussed in lecture?
- Cystocele (bladder)
- Rectocele (rectum)
- Enterocele (intestine)
107
What medical device do patients typically go home with post prolapse repair?
Foley catheter (ensures urethra won't be obstructed)
108
What are the three types of hysterectomy?
| * Partial= Uterus
* Total= Cervix and uterus (w/wo fallopian tubes)
109
What two types of cut are used in hysterectomies if an abdominal approach is indicated?
- Pfannenstiel (bikini cut)
- Midline
110
What is the most common surgical approach for hysterectomies?
LAVH
*Laparoscopic assisted vaginal hysterectomy*
111
What benefits does robotic surgery provide?
Increased safety profile
*Ex. Impotence rates decreased post implementation of robotic surgery for prostatectomies*
112
What are the pros and cons of robotic surgery?
- Improved dexterity
- Increased cost & OR time
113
What positioning is typically used with robotic surgery?
Extreme Trendelenburg
114
Robotic surgeries necessitate less fluid administration. Why?
Positioning (severe trendelenburg) results in extreme facial and airway edema.
115
What dye is it given for people with sulfa allergies?
Indigo carmine
116
Methylene blue for SLN mapping is C/I in what patient population?
Renal insufficiency
117
Which dye for SLN mapping is the most commonly used and causes rare anaphylaxis?
Lymphazurin
118
What would be the approximate size of a lesion removed in a lumpectomy (partial mastectomy)?
2.5 - 5 cm
119
In lieu of breast surgery, you notice the patient has received radiation and chemo, from what services would you seek an evaluation?
Cardio and pulmonary
120
Which are the breast reconstruction methods?
- Tissue expander
- Latissumus dorsi myocutaneous (LDM)
- Transverse rectus abdominals myocutaneous (TRAM)
- Deep inferior epigastric perforators (DIEP)
121
Position for a cholecystectomy:
Supine
R. Trendelenburg
122
Position for a cholecystectomy:
Supine
R. Trendelenburg
