Exam 3 General/Gynecologic/Breast Surgery [7/11/24] Flashcards
1
Q
When was the invention of laparoscopy and for what?
A
- First for diagnosis of gynecological conditions in 1970’s
- Then, for cholecystectomy in late 1980.
S2
2
Q
what is the first thing we do when performing a laparoscopy?
A
- creating a pneumoperitoneum
pneumoperitoneum: presence of air within the peritoneal cavity (google)
S3
3
Q
what does gastric insufflation of CO2 help with?
A
- identification off intreperitoneal space
- allows room to work
S3
4
Q
What occurs with the initial insufflation of the abdomen?
A
- Release of catecholamines & vasopressin.
- Arterial vasculature is compressed
S3
5
Q
What is the goal pressure in mmHg for gastric insufflation?
A
≤ 20 mmHg
12 - 15 mmHg is most common.
S3
6
Q
What causes increased CO₂ during laparoscopic surgeries?
A
- Positioning (frequently Trendelenburg)
- CO₂ insufflation (absorbed by peritoneum into the blood stream).
S4 Andy
7
Q
What are the pulmonary effects of insufflation?
A
- ↑ PaCO₂
- ↓ compliance 30-50%
- ↑ PIP
- ↓ FRC
- Atelectasis
S4
8
Q
In what laparoscopic position is atelectasis development most common?
A
Trendelenburg
S4- Andy
9
Q
How much change in pulmonary compliance occurs with gastric insufflation?
A
30 - 50% decrease in compliance
S4
10
Q
What causes the increased PaCO₂ in laparoscopic cases?
A
- Occurs from insuflation.
- The additional CO2 gets absorbed and transported to be blown off from the lungs causing increase PaCO2
S4 lecture
11
Q
When does the increase in PaCO₂ from gastric insufflation plateau?
A
10 - 15 min
S5
12
Q
How does the CRNA typically treat hypercarbia secondary to gastric insufflation?
A
- ↑Vm
- ↑ VT or RR
S5
13
Q
For hypercarbia related to gastric insuflation, what is the treatment early in the case vs late in the case?
A
Early Case:
* adjust settings to blow off excess CO2
Later Case:
* Since the stimulation to breath is from↑ CO₂ its beneficial to not treat to facilitate extubation.
S5
14
Q
Improper trocar placement can cuase pulmonay complications in laparoscopic cases. List these complications.
A
- SubQ emphysema, pneumothorax, pneumomediastinum
- Gas embolism
- Endobronchial intubation
GESPP (like GASPH)
S6 lecture
15
Q
What pulmonary complication is the result of CO₂ insufflation pushing the carina upwards?
A
- Endobronchial Intubation
- Migration of ETT from carina to the bronchus
- Occurs bc of diaphram elevation and cephaldad displacement of carina.
S6/S10
16
Q
- sub q emphysema/pneumothroax d/t improper placement of trocars usually resolves in how many mintutes?
- what do we want to monitor?
A
- usually resolves in 30-60 min
- monitor ventilation/oxygenation
S7
17
Q
how does a gas embolism develop during insufflation? What are the consequences of this?
A
- Gas infused directly into vessel
- Gas lock in vena cava causes obstruction to venous return.
- Massive CO drop (andy)
S8
18
Q
What are the s/s of gas embolism?
A
- ↓ EtCO₂ (best early sign)
- Tachycardia
- Cardiac Dysrhythmias
- ↓ BP w/ ↑ CVP
- Millwheel murmur
- Hypoxemia
S9
millwheel murmur- characteristic splashing auscultatory sound due to the presence of gas in the cardiac chambers
19
Q
What is the treatment for CO₂ gas embolism?
A
- Cessation of insufflation/release of pneumopertioneum
- Trendelenburg + left lateral
- Fluid bolus
- 100% O₂
- Aspiration of air
- Vasopressor support
S9
20
Q
How does a CRNA ensure endobronchial intubation hasn’t occured?
A
- monitor positon of ETT and adjust as needed
- pt has bilateral breath sounds
- pulse oximetry
S10
21
Q
At what intraperitoneal pressure do the hemodynamic effects of insufflation set in?
A
> 10 mmHg IAP
S11
22
Q
- What hemodynamic changes are seen with insufflation?
- When do these changes resolve?
A
- ↓ CO d/t high SVR
- proportional
- ↑ arterial pressure
- ↑ SVR/PVR
These resolve in several minutes
S11
23
Q
What drugs would be best for the hemodynamic effects (hypertension) from CO₂ insufflation?
A
- Want short term treatment medicine since the SE go away:
- Vapor
- Nitroglycerin
- Nicardipine (Cardene)
- Remifentanil
- Esmolol (lecture)
S12
24
Q
How much do cardiac arrhythmias increase with increased PaCO₂?
A
Trick question. Arrhythmias arise from hypoxia not from hypercarbia.
-Young Females are more prone to cardiac arrythmias
S13
25
What often causes cardiac arrythmias in laparoscopic cases?
* Reflex increases in vagal tone
* Peritoneal stretch
* electrocautery
* stretch of fallopian tubes
* Pulling on cervix
| S13
26
How would the bradycardia from vagal stimulation be treated?
- Limit insufflation pressure
- Glycopyrrolate (Robinol)
*Be prepared for bradycardia and asystole. Pretreat.*
| S13
27
what are the position effects of reverse trendelenburg?
* decreased preload → decreases CO
* venous statis
* favorable ventilation
* **Golden Position**⭐️
| S14
28
What are the position effects of trendelenburg?
* facial/pharyngeal/laryngeal airway edema
* increased CVP/CO
* increased intraocular pressure
* alterd pulmonary mechanics ↓FRC, TLV, Compliance
*this is very common position, but not user friendly.*
| S14
29
What kind of injuries can occur in lithotomy position?
* Peroneal nerve injury
* compartment syndrome
| S15
30
How do brachial plexus nerve injuries occur?
* overextension of arm
* shoulder support
| S15
31
Why did we go from laparotomy to laproscopy?
* more rapid recovery
* better maintenance of hemostasis
* less risk, less blood loss
| S16
32
if a physician uses laparscopy over laparotomy, what are the pt results?
* decreased postop pain
* decreased PONV
* less pulmonary dysfunction [but not none]
| S16
33
What are the surgical complications of laparoscopy?
* Intestinal Injury
* Vascular injury
* Burns
* Infection
| S17
34
What is the most common surgical complication of laparoscopy?
- Intestinal injury (perforation, CBD injury)
- *30-50% of serious complications*
- *may remain undiagnosed*
| S17
35
When is laparoscopy contraindicated?
Patient with ↑ ICP (tumor, trauma, hydrocephalus.)
*Relative CI per Kane*
| S17
36
What vascular injuries can occur d/t surgical comlication of laparoscopy
* gas embolism
* retroperitoneal hematomas often insidious
* great vessel injury emergent
| S17
## Footnote
insidious: proceeding in a gradual, subtle way, but with harmful effects.
37
Burns can occur as a complication of laparoscopy. What percent does it account for?
15-20%
| S17
38
Is there a high risk of infection as a complication of laparscopy?
very small risk
| S17
39
How do we do anesthesia for a laparoscopy?
* **Preop meds** - versed, PPI, H2, albuterol
* **GETA** - most will be intubated
* **LMA** - dont really use bc its harder to maintain a seal
* **Contolled ventilation**:
* normal ETCO2
* volume vs RR
* **IVF** for hemodynmaic changes [young vs elederly]
* **narcotics**
* **NMBD**
* **positioning**
Bolded whats on the PP
| S18
40
Is LMA a good option for Laparoscopic procedures?
* LMA lays in the epiglottis.
* Insuflation + position changes make it harder to maintain the seal = unable to ventilate properly.
| S18 lecture
41
What are the reasons for OGT/NGT insertion in laparoscopies?
Aspiration of stomach air so surgeon has better visualization.
| S18 lecture
42
Postop considerations for laproscopy
* oxygen
* prevention of N/V
* tx of surgical pain or referred pain
* discuss referred pain preop
| S19
43
what are the surgical care improvement project (SCIP) guidelines for laparoscopy?
* beta blockers within 24 hrs
* only if on BB at home.
* antibiotics within 1 hr of cut time
* temperature ≥ 36℃
* time out prior to incision
BATT (like bet, ill follow SCIP protocol)
| S20
44
* What are the two most common firstline antibiotics indicated by the SCIP protocol?
* What is the most common antibiotic indicated by the SCIP protocol for those with severe penicillin/cephalosporin allergy?
- Cefazolin [Ancef] & Cefoxitin [Mefoxin]
- Vancomycin [Vancocin]
| S20
## Footnote
dont have to memorize every drug, just know when its a reasonable antibiotic.
45
What are the indications for breast surgery
* Biopys
* Lumpectomy
* Simple mastectomy
* Modified radical
* Radical mastectomy
**B**ilateral **L**umps **S**imply **M**odify **R**adicals
| S23
46
what is a breast biopsy?
* excision of breast lesion with margins
| S23
47
what is a breast lumpectomy?
* partial mastectomy (taking part of the breast)
* lesion 2.5-5 cm
| S23
48
what is a simple mastectomy?
* taking all of the breast and nipple
* no lymph node involvement or poor surgical risk
| S23
49
what is a modified radical inculde in breast surgery?
* breast
* nipple
* axillary lymph nodes
* +/- reconstruction
| S23
50
what is a radical mastectomy?
entire breast, nodes, and pectoralis muscle
| S23
51
what are the preop considerations for breast surgery
* pre op meds
* SCIP antibiotics
* evaluation of cardio/pulm
* if radiation/chemo given prior
* pregnancy test
| S24
52
intraop considerations for biopsy vs mastectomy vs reconstruction
* Wire localization
* local vs LMA
* positioning
* excision vs reconstruction
* SLN mapping
* submit suspicious nodes for pathological frozen section evaluation
| S25
53
What is wire localization? What should the CRNA be cautious about?
* Wire placed in radiology for nodules that are deeper and harder to locate.
* The wire helps surgeon follow it down to the nodule to excise. If the wire is inside the area of concern it helps with confirmation.
* Wire comes taped down. Can cut the wire short BUT DO NOT PULL IT OUT.
| S25 lecture
54
what does SLN mapping stand for?
what are the 3 types used for SLN mapping?
* sentinel lymph node
* 3 types of dyes:
* methlene blue [c/i renal insuff]
* indigo carmine [c/i sulfa allergy]
* lymphazurin **normally used** d/t rare anaphylaxis
| S25
55
what medications should the CRNA give intraoperatively with breast sx?
* PONV prophylaxis
* Pain control:
* short acting vs long acting narcotics
* multi modal
* parvertebral blocks
* Use of NMBD
| S26
56
Why might a surgeon want NMBD worn off during breast surgery?
* bc of the long thoracix nerve
* responsible for keeping scapula close to the chest.
* if you mess with this → wing scapula.
* can fall away from posterior chest causing weird shoulder movement and pain if this nerve is messed with.
| S26 (lecture)
57
Types of reconstruction for breast sx
* tissue expander
* latissimus dorsi myocutaneous [LDM]
* transverse rectus abdominus myocutaneous [TRAM]
* deep inferior epigastric perforators [DIEP]
LDM, TRAM, DIEP are for more complex cases when everything has been removed and only skin and ribs are present. Only choose 1.
| S27
58
How are tissue expanders used for breast reconstriction?
* look like plastic donuts and are stuck inside where the breast tissue is.
* It’s injected with fluids to get to same size as native breast.
* work great with only breast is taken.
| S27
59
* What is a latissimus dorsi myocutaneous reconstruction [LDM]?
* LDM is common reffered to as?
* below scapula
* muscle and skin
* cut away as pedicle graft and tunnled through axilla
* Commonly referred lat flap
| S27
60
what is a transverse rectus abdominus myocutaneous [TRAM]?
* abdominal muscle, sub-q, skin
* remains attached to native blood supply
* mesh prothesis to abdomen
Lecture (for additional explanation)
* *Comes from belly & gets pulled up. Has nerve and native blood supply attachment. Feels like a tummy tuck bc the belly is stretched up to the chest.*
* *problem: muscle from belly is pulled to so it can’t support a lot of abdominal content. Need to put in a mesh or else can get hernias.*
| S27
61
What is a deep inferior epigastric perforators [DIEP]?
* skin and fat removed from abdomen [without muscle]
* denervates abdomen
Lecture (for additional information)
- *not as big of a flap bc muscle isnt taken.*
- *very vascular*
- *heals nicely*
- *not as much volume bc muscle isn’t taken but dont have to worry about hernia*
| S27
62
* What is the indication for a Nissen Fundoplication?
* To increase lower esophageal sphincter pressure
| S29
63
What conditions might require the nissen fundoplication?
* Complications of GERD
* Stricture
* Aspiration PNA
* Esophageal Ulcerations
* Barret's Esophagus
* Failure or unwillingness to commit to medication
| S29
64
Preoperative considered for nissen fundoplication:
* What drugs should be administered
* What should be documented preop?
* PPI
* Prokinetics drugs
* Document: esophageal hyperacidity
65
# Nissen fundoplication
How do prokinetic drugs work?
Which ones are commonly given?
- Strengthen LES & increase gastric emptying
- Metoclopramide (reglan) & Domperidone (Motilium)
- cisapride (Prepulsid or Propulsid) (ANDY)
| S30
66
How do PPI's work?
Examples?
* Blockade of ATPase in parietal cells to decrease acid production
* “prazoles”… nexium, prevacid, protonix, prilosec
| S30
67
What should be done Intra-operative for a nissen fundoplication
* Pre-op meds
* GETA/RSI
* OGT
* Positioning: Supine, low lithotomy, reverse Tburg.
* SCIP Abx
* Esophageal dilator
| S31
68
What position is indicated for nissen fundoplication?
Supine, Low lithotomy, reverse Tburb
| S31
69
* What piece of equipment (unique to Niessen Fundiplocations) should the CRNA be prepared to use?
* Why is this used (lecture)?
* **Esophageal Dilator 60F**
Lecture:
* Wrap the stomach around the esophagus with the sizer in place. When the sizer is removed thats how big of a hole is left to left food pass.
* using this as sizer bc when working laparoscopy we can’t touch or feel with the hand so we dont know how tight the stomach is being wrapped around the esophagus.
* dont stick the pointy end through the esophagus = esophageal fistula = medial emergency
* lube it up so it doesnt go through the esophageal wall.
| S31
70
What are the indications for Cholecystectomy?
* Symptomatic cholelithiasis [gallstones]
* Symptomatic cholecystitis [inflammation of gallbladder]
* 5F: female, forty, fair, flatulent, fat
| S33
71
In a Cholecystectomy, the surgeron must identify the triangle of calot. What are the borders for traingle of calot?
* cystic duct [*laterally*]
* common hepatic duct [*medially*]
* inferior surface of the liver [*superiorlly*]
| S32
## Footnote
REVIEW THIS CARD
72
What structures are isolated and stapled during a cholecystectomy?
- Cystic duct and cystic artery
| S32
73
Who is most at risk for gallbladder disease?
5 F's
- Female
- Forty
- Fair (caucasian)
- Flatulent
- Fat
| S33
74
Preop consideraions for emegent gallbladder surgery:
* What drugs should be given?
* How should you intubate these patients?
* Dugs:
- **Prokinetics**
- **Bicitra** [*to neutralize acid*] and possibly fluids if throwing up
- RSI bc full stomach
| S34
75
What position is a gallbladder placed in for surgery?
- Supine
- Reverse Tburg
- Left tilt [*right side up*]
| S35
76
Intraoperative considerations for cholelithiasis
* GETA
* OGT
* Position: Supine, reverse Tburg, Left tilt
* SCIP
* IOC (intraoperative cholangiogram) [*special kind of X-ray imaging that shows those bile ducts.*]
* May require *Endoscopic retrograde cholangiopancreatography* [ERCP} for choledocholithiasis
| S35
## Footnote
choledocholithiasis: stone on CBD
Cholelithiasis: stone in gallbladder
77
* When using intraoperative cholangiogram for gall bladder surgery, what is the concern if dye isnt moving?
* How do you treat this?
* Having a sphincter of Oddi spasm
* Give Glucagon
| S35
78
When would an ERCP be indicated?
**Choledocholithiasis** (the presence of at least one gallstone in the common bile duct)
| S35
79
What are indications for Spleenectomy?
- ITP (Immune thrombocytopenic purpura)
- Lymphoma
- Hemolytic anemia
- Trauma
| S37
80
What vaccines should have been received one week prior to spleenectomy (if not urgent)?
- Pneumococcal
- Meningococcal
- H. Influenza
| S38
## Footnote
Spleen isnt protective for thes organisms once it is taken out
81
Preoperative considerations for spleenectomy?
With what pathology would one expect left lower lobe atelectasis?
* Ensure proper vaccines are administered 1 week
* Evaluate for LLL atelactasis
* Enlarged spleen pushes on LLL making it hard to expand.
| S38
## Footnote
LLL atelectasis may indicate larger spleen that has bleeding, inflammation. LLL not able to expand normally becuase spleen is so big.
82
What are intraoperative considerations for Spleenectomy
* GETA
* Type and cross vs type and screen
* Xtra venous access (18g)
* Position: 45 right lateral decubitus with kidney rest and table flexed.
* SCIP abx
| S39
83
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.
| S39
84
What position would one place a spleenectomy patient in?
- 45° right lateral decubitus
- kidney rest, table flexed
| S39
## Footnote
lots of tape to prevent movement of patient while working
85
Bowel resection requires us to keep a close eye on what?
* Body temperature.
* Bowel loses fluid really fast so it can dry out and cause hypothermia and hypovolemia.
| S40-lecture
86
What are some indications for bowel resection?
- Ulcerative colitis
- Crohn's
- Diverticular disease
- Cancer
- Ischemic bowel
**DU CC Is** [like deuces]
| S41
87
What is necessary pre-operatively for bowel resection patients?
- Bowel prep
- μ-opioid antagonists
- Entereg aka alvimopan
- ERAS protocol
| S42
88
What is the ERAS protocol for bowel resection?
**Enhanced Recovery After Surgery**.
- Pre-op warming
- Multimodal anesthesia: gabapentin, tylenol, scopolamine
- Proper hydration preoperatively: gatorade
| S42
89
What would be the purpose of a μ-opioid antagonist prior to bowel resection?
Counteracts constipation effects of narcotic and results in a faster resolving ileus.
| S42-lecture
90
What are intra-operative considerations for bowel resection
* GETA: consider full stomach/aspiration risk
* OG v. NGT (scope or open)
* Position: supine or low lithotomy
* SCIP abx
* Albumin vs Crystalloid (think about this ahead of time)
* post op pain control (TAP block, epidural, multimodal)
| S43
91
What kind of fluids might the CRNA wants to administer for bowel resection?
* **Albumin** or hetastarch > crystallaoids
*Want something with more osmolarity*
| S43
92
What positions are used commonly for bowel resections?
* Supine & low lithotomy
(can range all the way to very high lithotomy)
| S43
93
What is the indication for appendectomy?
Suspected appendicitis
| S45
94
Why might appendectomy patients be dehydrated?
What are the most commonly used labs to note this dehydration?
What is one other pre-operative consideration?
- Dehydration d/t fever & N/V
- Hemoconcentration (H/H), ↑ BUN
- normal creatinine
- Always considered full stomach (emergent)
| S46
95
Intraoperative considerations for appendectomy?
* GETA with RSI: considered fill stomach/aspiration rsk
* OGT
* Position: supine, left arm tucked, trenelenburg
* SCIP abx
| S47
96
What positioning is utilized for appendectomy patients?
Supine, left arm tucked, trendelenburg (head down)
| S47
## Footnote
arms: leaves plenty of room for the surgeons
97
Which two gastric surgeries result in rapid initial weight loss?
* Sleeve Gastrectomy
* Gastric Bypass
| S48
98
Gastric Bypass Surgery:
* Weight loss:
* Reversible:
* Effects of nutrients:
* Risk:
* **Weight loss**: rapid initial
* **Reversible**: not reversible
* **Effects of nutrients**: protein/nutrient effected
* **Risk**: suture line x 2, malapsorption
| S48
99
Sleeve gastrectomy:
* Weight loss:
* Reversible:
* Effects of nutrients:
* Risk:
* **Weight loss**:rapid initial
* **Reversible**: not easily reversible
* **Effects of nutrients**: nutrients not affected
* **Risk**: suture line (peritonitis), over-eating
| S48
100
Lap Banding:
* Weight loss:
* Reversible:
* Effects of nutrients:
* Risk:
* **Weight loss:** slow, 55% excess over 5yrs
* **Reversible**: easily removed
* **Effects of nutrients**: nutrients not affected
* **Risk**: band erosion into stomach lining.
| S48
101
Lap banding has an ____ that allows us to control weight loss by restricting the passage of food.
* access port
Lecture
* access port looks like a portacath.
* as the balloon blows up, the size of the band narrows.
* as balloon deflates, the size inside the band expands.
| S48
102
What are some possible indications for Bariatric surgery?
* Morbid Obesity associated with:
* HTN
* DM
* OSA
* Asthma
* BMI > 35 w associated cormorbidties (listed above)
* BMI > 40
| S49
103
What possible homeopathic remedies for appetite suppression should be considered (and stopped) for patients receiving bariatric surgery?
* G - Supplements (gingko, green tea, etc.)
| S50
## Footnote
appetite suppresants
104
Prophylaxis for ____ is CRITICAL for bariatric surgeries.
VTE
| S50
105
Bariatric surgery patients commonly have undiagnosed ____. Because of this we need to do what?
* OSA
* assess the airway and limit pre-operative sedation
| S50
106
What position is typically used for bariatric surgeries? why?
- Reverse T, (Head up) at 30°
- Good pre-oxygenation
| S51
107
What positioning do obese patients generally not tolerate? So what kind of intubation technique should we use?
* Supine (or also head down)
* GETA/RSI
| S51
108
What are some intraoperative considerations for bariatric surgeries?
* Positioning
* GETA/RSI
* Induction based on end-point
* OGT
* Calipbration tube [banding] /methylene blue [sleeve]
| S51
109
When should the OGT be removed in bariatric surgeries?
* removal before stomach is stapled
| S51
110
What are long term concerns for patients post-operative bariatric surgery?
- Diarrhea
- Dysphagia (seen with banding)
- Protein malabsorption
- Less contact time, less bile/pancreatic enzymes
- Vitamin malabsorption
- A, D, E, K, B12, Ca
| S52
111
What vitamin malabsorptions can occur post bariatric surgery?
* A, D, E, K, B12, Calcium
| S52
112
What are some indications for conversion of laparoscopy to laparotomy?
- Obesity
- Adhesions
- Bleeding
- Unclear anatomy
- Staple misfire
- Inability to ventilate
Staples In Our Abdomen Break Us
| S54
113
What are some indications for exploratory laparotomy?
- Trauma
- Abdominal catastrophes (ex. ischemic bowel)
- Cancer staging
| S55
114
Intra-operative considerations for exploratory laparotomy?
* GETA
* Profound muscle relaxation (retractors)
* NGT
* Consider epidural placement
* Consider multi-modal pain control
* Keep warm!!!!
| S55
115
____ are necessary for the inevitable ileus in post-operative laparotomies.
NGT's
| S55- lecture
116
What surgeries are often at risk for PONV?
Gynecologic surgeries
| S57-lecture
117
Gynecologic surgeries are at risk for PONV. What risk factors for PONV exist with gynecologic surgeries?
- Female
- Opioids
- Volatile anesthetics
- Laparoscopy or laparotomy
| S57
118
What is removed in D&C surgeries?
What can D&C be helpful for?
* removes the endometrial lining of the uterus
* diagnosis and treats bleeding from uterus or cervix
* Patient groups: young adult - elderly.
| S59
119
If patients coming with D&C with retained products of conception, what complications can occur?
- Sepsis
- Hemorrhage
| S59
120
# general overview
What are intraop considered for Dilation &Curretage?
* Position: lithotomy
* GA
* No SCIP antibiotics
* can be combined with other procedures like hysteroscopy or conization
* Pitocin IV maybe needed
* Bradycardia
* Post op pain?
| S60
121
What would tend to cause bradycardia during a dilation and curettage (D&C) procedure?
* Cervix manipulation via the tenaculum
| S60-lecture
122
* What positioning is utilized for both a D&C and a D&E ?
* what injuries might occur with improper technique??
- Lithotomy w/ stirrups
- peroneal nerve injury and table causing injury to fingers
| S60
123
Which surgeries are SCIP antibiotics **not** indicated on?
D&C
| S60
124
What is a dilation and evacuation (D&E)?
* An abortion
* Accidental/missed abortion leading to bleeding
* Pitocin IV might be needed.
| S61
125
D&E is variable by state. What things might be required or needed?
* termination of pregnancy prior to viability [**20-24 weeks**]
* counseling/waiting period
* parental involvement
Invovlement as an anesthesia provider depends on your own belief.
| S61
126
Pitocin (oxytocin):
* Where is it screted from?
* What does it do?
* What is it similar to?
* How is it mixed?
* Secreted from Neurohypophysis [posterior pituitary
* It stimulate uterine contraction
* Similar to vasopressin: ↑ H₂O reabsorption from glomerular filtrate
* 20units/L
| S62
127
What is a hysteroscopy? What can it investigate
* A procedure allows for examination of the endometrial cavity
* Investigate intrauterine bleeding [IUB]
| S64
128
* What two fluids are used for hysteroscopy?
* What are the risk with these fluids?
* What shoud you ensure as a CRNA with fluids?
- **NS**: Na carries current which can cause burns when cautarizing.
- **Sorbitol**: can cause sugar deficiency or excess fructose. some people can have seizures.
* **Make sure IN=OUT** (whatever we inflate the uterus with, we need to make sure it comes back out)
| S64
129
What equipment should be used if NS is used in a hysteroscopy?
Bipolar Cautery
*Monopolar cautery + NS = burns*
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When should sorbitol be avoided with hysteroscopy?
With diabetic patients
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When should glycine irrigation be avoided?
Why is this?
* Avoided in liver patients due to the buildup of ammonia
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Intraop consideraton for hysteroscopy:
* Type of anesthetic?
* Position?
* SCIP protocol?
* Hemodynamic effect?
* Pain?
* Type of anesthetic: paracervical block vs GA
* Position: lithotomy
* SCIP protocol: Antibiotics
* Hemodynamic effect: bradycardia
* Pain: uncomfortable, pt feels the need to pee.
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What are the two typical anesthetic options for hysteroscopy?
- Paracervical block
- General w/ LMA
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What would most likely cause bradycardia during a hysteroscopy?
Vagal response of cervix manipulation w/ tenaculum
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What are urethral slings used to treat?
Stress Urinary Incontinence
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* Who is at risk of incontinence requiring a urethral sling?
* what percent of women can be affected by that?
- Multiparous women (older)
- 1/4 Nulliparous, college athletes
- 15-60% of women affected
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Why would a patient need a sling procedure? What is the sling made of?
* Due to loss of support to the bladder neck and pelvic floor (SUI)
* Stress urinary leak point (abdominal leak point pressure)
* Made of a prolene mesh
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Intra-op considerations for urethral slings:
* position:
* anesthetic:
* SCIP:
* Pain :
* Position: Lithotomy
* Anesthetic: GA (LMA)
* SCIP: antibiotics
* post op pain? slightly uncomfortable so may need small dose of fentanyl in OR
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What type of anesthesia is typically performed for urethral sling patients?
General w/ LMA
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