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Mar: Sem 3 - Principles I > Exam 3 General/Gynecologic/Breast Surgery [7/11/24] > Flashcards

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

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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

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3
Q

what does gastric insufflation of CO2 help with?

A
  • identification off intreperitoneal space
  • allows room to work

S3

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4
Q

What occurs with the initial insufflation of the abdomen?

A
  • Release of catecholamines & vasopressin.
  • Arterial vasculature is compressed

S3

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5
Q

What is the goal pressure in mmHg for gastric insufflation?

A

≤ 20 mmHg

12 - 15 mmHg is most common.

S3

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6
Q

What causes increased CO₂ during laparoscopic surgeries?

A
  1. Positioning (frequently Trendelenburg)
  2. CO₂ insufflation (absorbed by peritoneum into the blood stream).

S4 Andy

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7
Q

What are the pulmonary effects of insufflation?

A
  • ↑ PaCO₂
  • ↓ compliance 30-50%
  • ↑ PIP
  • ↓ FRC
  • Atelectasis

S4

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8
Q

In what laparoscopic position is atelectasis development most common?

A

Trendelenburg

S4- Andy

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9
Q

How much change in pulmonary compliance occurs with gastric insufflation?

A

30 - 50% decrease in compliance

S4

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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

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11
Q

When does the increase in PaCO₂ from gastric insufflation plateau?

A

10 - 15 min

S5

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12
Q

How does the CRNA typically treat hypercarbia secondary to gastric insufflation?

A
  • ↑Vm
    • ↑ VT or RR

S5

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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

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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

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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

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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

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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

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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

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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

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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

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21
Q

At what intraperitoneal pressure do the hemodynamic effects of insufflation set in?

A

> 10 mmHg IAP

S11

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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

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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

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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

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25
Q

What often causes cardiac arrythmias in laparoscopic cases?

A
  • Reflex increases in vagal tone
    • Peritoneal stretch
    • electrocautery
    • stretch of fallopian tubes
    • Pulling on cervix

S13

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26
Q

How would the bradycardia from vagal stimulation be treated?

A
  • Limit insufflation pressure
  • Glycopyrrolate (Robinol)

Be prepared for bradycardia and asystole. Pretreat.

S13

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27
Q

what are the position effects of reverse trendelenburg?

A
  • decreased preload → decreases CO
  • venous statis
  • favorable ventilation
  • Golden Position⭐️

S14

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28
Q

What are the position effects of trendelenburg?

A
  • 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

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29
Q

What kind of injuries can occur in lithotomy position?

A
  • Peroneal nerve injury
  • compartment syndrome

S15

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30
Q

How do brachial plexus nerve injuries occur?

A
  • overextension of arm
  • shoulder support

S15

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31
Q

Why did we go from laparotomy to laproscopy?

A
  • more rapid recovery
  • better maintenance of hemostasis
  • less risk, less blood loss

S16

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32
Q

if a physician uses laparscopy over laparotomy, what are the pt results?

A
  • decreased postop pain
  • decreased PONV
  • less pulmonary dysfunction [but not none]

S16

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33
Q

What are the surgical complications of laparoscopy?

A
  • Intestinal Injury
  • Vascular injury
  • Burns
  • Infection

S17

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34
Q

What is the most common surgical complication of laparoscopy?

A
  • Intestinal injury (perforation, CBD injury)
  • 30-50% of serious complications
  • may remain undiagnosed

S17

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35
Q

When is laparoscopy contraindicated?

A

Patient with ↑ ICP (tumor, trauma, hydrocephalus.)

Relative CI per Kane

S17

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36
Q

What vascular injuries can occur d/t surgical comlication of laparoscopy

A
  • gas embolism
  • retroperitoneal hematomas often insidious
  • great vessel injury emergent

S17

insidious: proceeding in a gradual, subtle way, but with harmful effects.

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37
Q

Burns can occur as a complication of laparoscopy. What percent does it account for?

A

15-20%

S17

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38
Q

Is there a high risk of infection as a complication of laparscopy?

A

very small risk

S17

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39
Q

How do we do anesthesia for a laparoscopy?

A
  • 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

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40
Q

Is LMA a good option for Laparoscopic procedures?

A
  • LMA lays in the epiglottis.
  • Insuflation + position changes make it harder to maintain the seal = unable to ventilate properly.

S18 lecture

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41
Q

What are the reasons for OGT/NGT insertion in laparoscopies?

A

Aspiration of stomach air so surgeon has better visualization.

S18 lecture

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42
Q

Postop considerations for laproscopy

A
  • oxygen
  • prevention of N/V
  • tx of surgical pain or referred pain
    • discuss referred pain preop

S19

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43
Q

what are the surgical care improvement project (SCIP) guidelines for laparoscopy?

A
  • 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

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44
Q
  • 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?
A
  • Cefazolin [Ancef] & Cefoxitin [Mefoxin]
  • Vancomycin [Vancocin]

S20

dont have to memorize every drug, just know when its a reasonable antibiotic.

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45
Q

What are the indications for breast surgery

A
  • Biopys
  • Lumpectomy
  • Simple mastectomy
  • Modified radical
  • Radical mastectomy

Bilateral Lumps Simply Modify Radicals

S23

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46
Q

what is a breast biopsy?

A
  • excision of breast lesion with margins

S23

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47
Q

what is a breast lumpectomy?

A
  • partial mastectomy (taking part of the breast)
  • lesion 2.5-5 cm

S23

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48
Q

what is a simple mastectomy?

A
  • taking all of the breast and nipple
  • no lymph node involvement or poor surgical risk

S23

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49
Q

what is a modified radical inculde in breast surgery?

A
  • breast
  • nipple
  • axillary lymph nodes
  • +/- reconstruction

S23

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50
Q

what is a radical mastectomy?

A

entire breast, nodes, and pectoralis muscle

S23

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51
Q

what are the preop considerations for breast surgery

A
  • pre op meds
  • SCIP antibiotics
  • evaluation of cardio/pulm
    • if radiation/chemo given prior
  • pregnancy test

S24

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52
Q

intraop considerations for biopsy vs mastectomy vs reconstruction

A
  • Wire localization
  • local vs LMA
  • positioning
    • excision vs reconstruction
  • SLN mapping
  • submit suspicious nodes for pathological frozen section evaluation

S25

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53
Q

What is wire localization? What should the CRNA be cautious about?

A
  • 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

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54
Q

what does SLN mapping stand for?
what are the 3 types used for SLN mapping?

A
  • 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

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55
Q

what medications should the CRNA give intraoperatively with breast sx?

A
  • PONV prophylaxis
  • Pain control:
    • short acting vs long acting narcotics
    • multi modal
    • parvertebral blocks
  • Use of NMBD

S26

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56
Q

Why might a surgeon want NMBD worn off during breast surgery?

A
  • 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
Q

Types of reconstruction for breast sx

A
  • 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
Q

How are tissue expanders used for breast reconstriction?

A
  • 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
Q
  • What is a latissimus dorsi myocutaneous reconstruction [LDM]?
  • LDM is common reffered to as?
A
  • below scapula
  • muscle and skin
  • cut away as pedicle graft and tunnled through axilla
  • Commonly referred lat flap

S27

60
Q

what is a transverse rectus abdominus myocutaneous [TRAM]?

A
  • 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
Q

What is a deep inferior epigastric perforators [DIEP]?

A
  • 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
Q
  • What is the indication for a Nissen Fundoplication?
A
  • To increase lower esophageal sphincter pressure

S29

63
Q

What conditions might require the nissen fundoplication?

A
  • Complications of GERD
    • Stricture
    • Aspiration PNA
    • Esophageal Ulcerations
    • Barret’s Esophagus
  • Failure or unwillingness to commit to medication

S29

64
Q

Preoperative considered for nissen fundoplication:
* What drugs should be administered
* What should be documented preop?

A
  • PPI
  • Prokinetics drugs
  • Document: esophageal hyperacidity
65
Q

Nissen fundoplication

How do prokinetic drugs work?
Which ones are commonly given?

A
  • Strengthen LES & increase gastric emptying
  • Metoclopramide (reglan) & Domperidone (Motilium)
    • cisapride (Prepulsid or Propulsid) (ANDY)

S30

66
Q

How do PPI’s work?
Examples?

A
  • Blockade of ATPase in parietal cells to decrease acid production
  • “prazoles”… nexium, prevacid, protonix, prilosec

S30

67
Q

What should be done Intra-operative for a nissen fundoplication

A
  • Pre-op meds
  • GETA/RSI
  • OGT
  • Positioning: Supine, low lithotomy, reverse Tburg.
  • SCIP Abx
  • Esophageal dilator

S31

68
Q

What position is indicated for nissen fundoplication?

A

Supine, Low lithotomy, reverse Tburb

S31

69
Q
  • What piece of equipment (unique to Niessen Fundiplocations) should the CRNA be prepared to use?
  • Why is this used (lecture)?
A
  • 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
Q

What are the indications for Cholecystectomy?

A
  • Symptomatic cholelithiasis [gallstones]
  • Symptomatic cholecystitis [inflammation of gallbladder]
  • 5F: female, forty, fair, flatulent, fat

S33

71
Q

In a Cholecystectomy, the surgeron must identify the triangle of calot. What are the borders for traingle of calot?

A
  • cystic duct [laterally]
  • common hepatic duct [medially]
  • inferior surface of the liver [superiorlly]

S32

REVIEW THIS CARD

72
Q

What structures are isolated and stapled during a cholecystectomy?

A
  • Cystic duct and cystic artery

S32

73
Q

Who is most at risk for gallbladder disease?

A

5 F’s

  • Female
  • Forty
  • Fair (caucasian)
  • Flatulent
  • Fat

S33

74
Q

Preop consideraions for emegent gallbladder surgery:
* What drugs should be given?
* How should you intubate these patients?

A
  • Dugs:
    • Prokinetics
    • Bicitra [to neutralize acid] and possibly fluids if throwing up
  • RSI bc full stomach

S34

75
Q

What position is a gallbladder placed in for surgery?

A
  • Supine
  • Reverse Tburg
  • Left tilt [right side up]

S35

76
Q

Intraoperative considerations for cholelithiasis

A
  • 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

choledocholithiasis: stone on CBD
Cholelithiasis: stone in gallbladder

77
Q
  • When using intraoperative cholangiogram for gall bladder surgery, what is the concern if dye isnt moving?
  • How do you treat this?
A
  • Having a sphincter of Oddi spasm
  • Give Glucagon

S35

78
Q

When would an ERCP be indicated?

A

Choledocholithiasis (the presence of at least one gallstone in the common bile duct)

S35

79
Q

What are indications for Spleenectomy?

A
  • ITP (Immune thrombocytopenic purpura)
  • Lymphoma
  • Hemolytic anemia
  • Trauma

S37

80
Q

What vaccines should have been received one week prior to spleenectomy (if not urgent)?

A
  • Pneumococcal
  • Meningococcal
  • H. Influenza

S38

Spleen isnt protective for thes organisms once it is taken out

81
Q

Preoperative considerations for spleenectomy?
With what pathology would one expect left lower lobe atelectasis?

A
  • Ensure proper vaccines are administered 1 week
  • Evaluate for LLL atelactasis
    • Enlarged spleen pushes on LLL making it hard to expand.

S38

LLL atelectasis may indicate larger spleen that has bleeding, inflammation. LLL not able to expand normally becuase spleen is so big.

82
Q

What are intraoperative considerations for Spleenectomy

A
  • 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
Q

Differentiate a type and screen and a type and cross. (very superficially)

A
  • Type & Screen = blood type identified
  • Type and Cross = blood type identified and bags are ready down in blood bank.

S39

84
Q

What position would one place a spleenectomy patient in?

A
  • 45° right lateral decubitus
  • kidney rest, table flexed

S39

lots of tape to prevent movement of patient while working

85
Q

Bowel resection requires us to keep a close eye on what?

A
  • Body temperature.
  • Bowel loses fluid really fast so it can dry out and cause hypothermia and hypovolemia.

S40-lecture

86
Q

What are some indications for bowel resection?

A
  • Ulcerative colitis
  • Crohn’s
  • Diverticular disease
  • Cancer
  • Ischemic bowel

DU CC Is [like deuces]

S41

87
Q

What is necessary pre-operatively for bowel resection patients?

A
  • Bowel prep
  • μ-opioid antagonists
    • Entereg aka alvimopan
  • ERAS protocol

S42

88
Q

What is the ERAS protocol for bowel resection?

A

Enhanced Recovery After Surgery.
- Pre-op warming
- Multimodal anesthesia: gabapentin, tylenol, scopolamine
- Proper hydration preoperatively: gatorade

S42

89
Q

What would be the purpose of a μ-opioid antagonist prior to bowel resection?

A

Counteracts constipation effects of narcotic and results in a faster resolving ileus.

S42-lecture

90
Q

What are intra-operative considerations for bowel resection

A
  • 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
Q

What kind of fluids might the CRNA wants to administer for bowel resection?

A
  • Albumin or hetastarch > crystallaoids

Want something with more osmolarity

S43

92
Q

What positions are used commonly for bowel resections?

A
  • Supine & low lithotomy

(can range all the way to very high lithotomy)

S43

93
Q

What is the indication for appendectomy?

A

Suspected appendicitis

S45

94
Q

Why might appendectomy patients be dehydrated?

What are the most commonly used labs to note this dehydration?

What is one other pre-operative consideration?

A
  • Dehydration d/t fever & N/V
  • Hemoconcentration (H/H), ↑ BUN
    • normal creatinine
  • Always considered full stomach (emergent)

S46

95
Q

Intraoperative considerations for appendectomy?

A
  • GETA with RSI: considered fill stomach/aspiration rsk
  • OGT
  • Position: supine, left arm tucked, trenelenburg
  • SCIP abx

S47

96
Q

What positioning is utilized for appendectomy patients?

A

Supine, left arm tucked, trendelenburg (head down)

S47

arms: leaves plenty of room for the surgeons

97
Q

Which two gastric surgeries result in rapid initial weight loss?

A
  • Sleeve Gastrectomy
  • Gastric Bypass

S48

98
Q

Gastric Bypass Surgery:
* Weight loss:
* Reversible:
* Effects of nutrients:
* Risk:

A
  • Weight loss: rapid initial
  • Reversible: not reversible
  • Effects of nutrients: protein/nutrient effected
  • Risk: suture line x 2, malapsorption

S48

99
Q

Sleeve gastrectomy:
* Weight loss:
* Reversible:
* Effects of nutrients:
* Risk:

A
  • Weight loss:rapid initial
  • Reversible: not easily reversible
  • Effects of nutrients: nutrients not affected
  • Risk: suture line (peritonitis), over-eating

S48

100
Q

Lap Banding:
* Weight loss:
* Reversible:
* Effects of nutrients:
* Risk:

A
  • Weight loss: slow, 55% excess over 5yrs
  • Reversible: easily removed
  • Effects of nutrients: nutrients not affected
  • Risk: band erosion into stomach lining.

S48

101
Q

Lap banding has an ____ that allows us to control weight loss by restricting the passage of food.

A
  • 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
Q

What are some possible indications for Bariatric surgery?

A
  • Morbid Obesity associated with:
    • HTN
    • DM
    • OSA
    • Asthma
  • BMI > 35 w associated cormorbidties (listed above)
  • BMI > 40

S49

103
Q

What possible homeopathic remedies for appetite suppression should be considered (and stopped) for patients receiving bariatric surgery?

A
  • G - Supplements (gingko, green tea, etc.)

S50

appetite suppresants

104
Q

Prophylaxis for ____ is CRITICAL for bariatric surgeries.

A

VTE

S50

105
Q

Bariatric surgery patients commonly have undiagnosed ____. Because of this we need to do what?

A
  • OSA
  • assess the airway and limit pre-operative sedation

S50

106
Q

What position is typically used for bariatric surgeries? why?

A
  • Reverse T, (Head up) at 30°
  • Good pre-oxygenation

S51

107
Q

What positioning do obese patients generally not tolerate? So what kind of intubation technique should we use?

A
  • Supine (or also head down)
  • GETA/RSI

S51

108
Q

What are some intraoperative considerations for bariatric surgeries?

A
  • Positioning
  • GETA/RSI
  • Induction based on end-point
  • OGT
  • Calipbration tube [banding] /methylene blue [sleeve]

S51

109
Q

When should the OGT be removed in bariatric surgeries?

A
  • removal before stomach is stapled

S51

110
Q

What are long term concerns for patients post-operative bariatric surgery?

A
  • Diarrhea
  • Dysphagia (seen with banding)
  • Protein malabsorption
    • Less contact time, less bile/pancreatic enzymes
  • Vitamin malabsorption
    • A, D, E, K, B12, Ca

S52

111
Q

What vitamin malabsorptions can occur post bariatric surgery?

A
  • A, D, E, K, B12, Calcium

S52

112
Q

What are some indications for conversion of laparoscopy to laparotomy?

A
  • Obesity
  • Adhesions
  • Bleeding
  • Unclear anatomy
  • Staple misfire
  • Inability to ventilate

Staples In Our Abdomen Break Us

S54

113
Q

What are some indications for exploratory laparotomy?

A
  • Trauma
  • Abdominal catastrophes (ex. ischemic bowel)
  • Cancer staging

S55

114
Q

Intra-operative considerations for exploratory laparotomy?

A
  • GETA
  • Profound muscle relaxation (retractors)
  • NGT
  • Consider epidural placement
  • Consider multi-modal pain control
  • Keep warm!!!!

S55

115
Q

____ are necessary for the inevitable ileus in post-operative laparotomies.

A

NGT’s

S55- lecture

116
Q

What surgeries are often at risk for PONV?

A

Gynecologic surgeries

S57-lecture

117
Q

Gynecologic surgeries are at risk for PONV. What risk factors for PONV exist with gynecologic surgeries?

A
  • Female
  • Opioids
  • Volatile anesthetics
  • Laparoscopy or laparotomy

S57

118
Q

What is removed in D&C surgeries?
What can D&C be helpful for?

A
  • removes the endometrial lining of the uterus
  • diagnosis and treats bleeding from uterus or cervix
    • Patient groups: young adult - elderly.

S59

119
Q

If patients coming with D&C with retained products of conception, what complications can occur?

A
  • Sepsis
  • Hemorrhage

S59

120
Q

general overview

What are intraop considered for Dilation &Curretage?

A
  • 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
Q

What would tend to cause bradycardia during a dilation and curettage (D&C) procedure?

A
  • Cervix manipulation via the tenaculum

S60-lecture

122
Q
  • What positioning is utilized for both a D&C and a D&E ?
  • what injuries might occur with improper technique??
A
  • Lithotomy w/ stirrups
  • peroneal nerve injury and table causing injury to fingers

S60

123
Q

Which surgeries are SCIP antibiotics not indicated on?

A

D&C

S60

124
Q

What is a dilation and evacuation (D&E)?

A
  • An abortion
  • Accidental/missed abortion leading to bleeding
  • Pitocin IV might be needed.

S61

125
Q

D&E is variable by state. What things might be required or needed?

A
  • 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
Q

Pitocin (oxytocin):
* Where is it screted from?
* What does it do?
* What is it similar to?
* How is it mixed?

A
  • Secreted from Neurohypophysis [posterior pituitary
  • It stimulate uterine contraction
  • Similar to vasopressin: ↑ H₂O reabsorption from glomerular filtrate
  • 20units/L

S62

127
Q

What is a hysteroscopy? What can it investigate

A
  • A procedure allows for examination of the endometrial cavity
  • Investigate intrauterine bleeding [IUB]

S64

128
Q
  • What two fluids are used for hysteroscopy?
  • What are the risk with these fluids?
  • What shoud you ensure as a CRNA with fluids?
A
  • 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
Q

What equipment should be used if NS is used in a hysteroscopy?

A

Bipolar Cautery

Monopolar cautery + NS = burns

S64 - ANDY

130
Q

When should sorbitol be avoided with hysteroscopy?

A

With diabetic patients

S64- ANDY

131
Q

When should glycine irrigation be avoided?
Why is this?

A
  • Avoided in liver patients due to the buildup of ammonia

S64- ANDY

132
Q

Intraop consideraton for hysteroscopy:
* Type of anesthetic?
* Position?
* SCIP protocol?
* Hemodynamic effect?
* Pain?

A
  • Type of anesthetic: paracervical block vs GA
  • Position: lithotomy
  • SCIP protocol: Antibiotics
  • Hemodynamic effect: bradycardia
  • Pain: uncomfortable, pt feels the need to pee.

S65

133
Q

What are the two typical anesthetic options for hysteroscopy?

A
  • Paracervical block
  • General w/ LMA

S65

134
Q

What would most likely cause bradycardia during a hysteroscopy?

A

Vagal response of cervix manipulation w/ tenaculum

S64

135
Q

What are urethral slings used to treat?

A

Stress Urinary Incontinence

S66 lecture

136
Q
  • Who is at risk of incontinence requiring a urethral sling?
  • what percent of women can be affected by that?
A
  • Multiparous women (older)
  • 1/4 Nulliparous, college athletes
  • 15-60% of women affected

S67

137
Q

Why would a patient need a sling procedure? What is the sling made of?

A
  • 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

S67

138
Q

Intra-op considerations for urethral slings:
* position:
* anesthetic:
* SCIP:
* Pain :

A
  • Position: Lithotomy
  • Anesthetic: GA (LMA)
  • SCIP: antibiotics
  • post op pain? slightly uncomfortable so may need small dose of fentanyl in OR

S68

139
Q

What type of anesthesia is typically performed for urethral sling patients?

A

General w/ LMA

S68

Mar: Sem 3 - Principles I (29 decks)

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