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NUNA 692 Principles III > Exam II Anesthesia for Laparoscopic Endoscopic Procedures > Flashcards

Exam II Anesthesia for Laparoscopic Endoscopic Procedures Flashcards

1
Q

Advantages of laparoscopic procedures (7)

A
  • less tissue trauma
  • reduced postop pain
  • shorter hospital stays
  • more rapid return to normal activities
  • significant cost savings
  • less potential for postoperative complications such as development of an ileus
  • improved cosmetic results
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2
Q

Indications for laparoscopic procedures are an ever-growing list of procedures including:

A
  • cholecystectomy
  • appendectomy
  • Fundoplication
  • inguinal hernia repair
  • GYN: tubal ligation, myomectomy, assisted hysterectomy, oophorectomy, lysis of adhesions, fulgartion of endometriosis, removal of ectopic pregnancies/tubal repair, diagnostic procedures, ovarian cystectomy
  • colon resection
  • splenectomy
  • nephrectomy
  • liver biopsy
  • diastasis repair
  • bariatric surgeries
  • undescended testicles
  • prostatectomy
  • cystectomy
  • robotic procedures
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3
Q

Lap absolute contraindications (6)

A
  • bowel obstruction
  • ileus
  • peritonitis
  • intraperitoneal hemorrhage
  • diaphragmatic hernia
  • severe cardiopulmonary disease (CHF)
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4
Q

Lap relative CIs: (8)

A
  • extremes of weight
  • inflammatory bowel disease
  • presence of large abdominal masses
  • advanced Intra-uterine pregnancy
  • increased ICPs
  • VP shunts
  • coagulopathy
  • previous abdominal surgeries with adhesions
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5
Q

Uterus remains in the _____ during the _____ _____ to allow safe insertion of the Veress needle through the _____

A

Pelvis
First trimester
Umbilicus

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6
Q

The enlarged uterus after the ____ week interferes with _____

A

23rd
Visualization

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7
Q

Closely monitor _____ in pregnant patients to maintain slightly _____ state in mother

A

PaCO2
Alkalotic

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8
Q

Place pregnant patient in ____-_____ _____-______ displacement

A

30-degree
Left-uterine

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9
Q

Limit intraperitoneal pressures in pregnant women to ____ ____

A

12 mmHg

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10
Q

Monitor fetal ____ ____ throughout with ______ ultrasound

A

Heart rate
Transvaginal

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11
Q

FOUR potential causes of major physiologic changes during laparoscopy we need to know:

A
  1. Creation of the pneumoperitoneum
  2. Potential for systemic absorption of CO2
  3. Initial trendelenburg position
  4. Reverse trendelenburg position
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12
Q

What is a pneumoperitoneum?

A

Insufflation of the peritoneal cavity with CO2 (air, N2O, helium, and O2)

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13
Q

_____ and _____ caused greater hemodynamic depression with pneumoperitoneum if embolized into venous vasculature and caused death at much smaller volumes

A

Helium and argon

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14
Q

____ is the safest gas to use with pneumoperitoneum

A

CO2

Be sure the tank is truly only CO2 bc it can be combined with O2 and still have the same PIN index. If the tank has greater than 7% CO2 it has the same PIN index. Potential for combustion

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15
Q

Characteristics of pneumoperitoneum: doesn’t support ______

A

Combustion

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16
Q

Characteristics of pneumoperitoneum: Blood solubility enhances ____ _____, decreasing risk of ____ _____

A

Tissue diffusion
Gas emboli

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17
Q

Characteristics of pneumoperitoneum: More pain due to _______ irritation

A

Diaphragmatic

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18
Q

Characteristics of pneumoperitoneum: Hyper_____, _____ acidosis, cardiac ______

A

Hypercarbia
Respiratory acidosis
Cardiac dysrhythmias

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19
Q

Advantage of pneumoperitoneum: separates the ______ _____ from the _____ of the peritoneal cavity to optimize ______ and access

A

Abdominal wall
Contents
Visualization

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20
Q

Disadvantage of pneumoperitoneum: limits surgeon’s freedom of ______, choice of _____, involves risk of significant complications r/t use of _____

A

Movement
Instruments
CO2

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21
Q

Procedure for creating a pneumoperitoneum: inject LA into the _____ area

A

Umbilical

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22
Q

Procedure for creating a pneumoperitoneum: Insert _____ _____ via anesthetized area into peritoneal cavity

A

Veress needle

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23
Q

Procedure for creating a pneumoperitoneum: Insufflate the cavity with CO2 at a pressure less than ___ ____ (___)

A

19 mmHg (3L)

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24
Q

Procedure for creating a pneumoperitoneum: Once distended, insufflator placed in _____ mode to maintain pneumoperitoneum at ____ ____

A

Automatic mode
12 mmHg

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25
Q

Procedure for creating a pneumoperitoneum: Intraabdominal pressure is maintained between __-__ mmHg

A

12-15 mmHg

This is an important time in the procedure as it is during this time that the patient is at highest risk for serious complications

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26
Q

Retroperitoneoscopic adrenalectomy - small cavity created in the _____ _____ and CO2 insufflation pressure to __-__ mmHg

A

Lumbodorsay lascia
15-20 mmHg

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27
Q

Traumatic injuries: unintentional injuries to abdominal organs, insertion of ____ ____, and ____.

A

Veress needle and trocars
(Aorta/vascular, intestinal walls, urinary tract)

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28
Q

Traumatic injuries: unintentional injuries to abdominal organs, insertion of ____ ____, and ____.

A

Veress needle and trocars
(Aorta/vascular, intestinal walls, urinary tract)

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29
Q

Traumatic injuries: More than ___ of complications occur during entry and insertion of trocars

A

50%

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30
Q

30-50% of injuries ____ diagnosed intraoperatively resulting in mortality of __-___

A

Aren’t
3.5-5%

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31
Q

Traumatic injuries: Massive hemorrhage due to _____ of _____ or _____ of _____ with stretching of pre-existing splenic adhesions

A

Penetration of vessels
Rupture of spleen

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32
Q

Traumatic injuries: Intestinal injuries __-__% of surgeries with less than __% of injuries recognized at the time of surgery including (4)

A

0.3-0.5%
50%
Including: peritonitis, sepsis, resp failure, multi-organ failure

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33
Q

Traumatic injuries: _____ _____ injury occurs in 0.5-8.3% of cases

A

Urinary tract

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34
Q

Traumatic injuries: _____ ____ to check for urinary structure damage or looking for ____ in catheter

A

Methylene blue
Blood

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35
Q

Risk factors for injuries during pneumoperitoneum: (7)

A
  • body Habitus
  • anatomic anomalies
  • prior surgeries
  • surgical skill
  • degree of abdominal elevation during trocar placement
  • patient position
  • volume of gas insufflation
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36
Q

_____ _____ due to improper placement of the needle between facial planes in the muscle

A

Subcutaneous emphysema

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37
Q

Subcutaneous emphysema can cause ____ issues

A

Airway

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38
Q

With SC emphysema, consider leaving patient ____ until _____

A

Intubated
Reabsorbed

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39
Q

Physiologic changes associated with pneumoperitoneum depend on: (8)

A
  • intraabdominal pressure attained
  • volume of CO2 absorbed
  • patient position
  • patient age, comorbidities
  • patient’s intravascular volume
  • ventilators technique
  • surgical conditions/time
  • anesthetic agents used
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40
Q

Physiologic changes associated with pneumoperitoneum: increased ____, ____, ____ and initial increase in _____, and initial decrease in _____

A

Increased SVR, MAP, HR, initial increase in CVP, and initial decrease in cardiac index

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41
Q

Physiologic changes associated with pneumoperitoneum: initial increase of CVP may have decrease due to ____ ____, _____ will have greater effect than pneumo

A

Other factors
Position

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42
Q

Physiologic changes associated with pneumoperitoneum: initial decrease in cardiac index (50% baseline - proportional to the ____ ____ achieved)

A

IA pressure

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43
Q

Initially CVP increases due to to _____ of abdominal _____ _____

A

Redistribution
Blood volume

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44
Q

Ultimately, ____ ____ decreases, but filling pressures increase. This is related to the transmitted pressure into the ____ _____. Don’t trust filling pressures to correlate to _____.

A

Venous return
Thorax cavity
Volume

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45
Q

Elevated levels of _____ (___) early and increased _____ later cause increased SVR

A

Vasopressin (ADH)
Catecholamines

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46
Q

Elevated Vasopressin: Higher catecholamines r/t pressure of __ ____ v. __ ____
[Physiologic changes associated with pneumoperitoneum]

A

20 torr v. 10 torr

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47
Q

Decreased CO is r/t decreased ____ ____, r/t _____ and ____ ______ causing reduced stroke volume
[Physiologic changes associated with pneumoperitoneum]

A

Venous return
Pneumo
Reverse trendelenburg

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48
Q

It is not unusual for CO to attempt to maintain r/t increase in ____
[Physiologic changes associated with pneumoperitoneum]

A

HR

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49
Q

It is reported that decreases in CO is only r/t intraabdominal pressures that exceed ___ torr or __ torr if GYN procedures
[Physiologic changes associated with pneumoperitoneum]

A

16
20

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50
Q

The decrease in CO can be minimized to a 20% drop if ____ are _____ and the patient is ______ versus a 50% drop in control patients
[Physiologic changes associated with pneumoperitoneum]

A

Legs are wrapped
Normovolemic

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51
Q

Decreased stroke volume is r/t decreased ____ ____
[Physiologic changes associated with pneumoperitoneum]

A

Venous return

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52
Q

Decreased stroke volume can be offset by: (3)
[Physiologic changes associated with pneumoperitoneum]

A
  • perioperative hydration
  • changes in pt position
  • compression stockings
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53
Q

______ with initial insufflation
[Physiologic changes associated with pneumoperitoneum]

A

Bradycardia

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54
Q

_____ ____ with high pressure insufflation
[Physiologic changes associated with pneumoperitoneum]

A

Prolonged QT

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55
Q

Physiologic changes associated with pneumoperitoneum: increased myocardial _____ _____ initially followed by sustained decrease in _____

A

Filling pressures
Preload (decreased venous return)

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56
Q

Physiologic changes associated with pneumoperitoneum: increased _____ blood flow and _____ pressure - hyperventilation does not effect however hypo ventilation makes it worse

A

Cerebral
Intracranial

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57
Q

Physiologic changes associated with pneumoperitoneum: decreased ____, _____, and _____ blood flow

A

Renal, portal, and splanchnic (decreased GFR, UOP, and creatinine clearance)

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58
Q

Increased filling pressures lead to compression of abd ____ ____ which pushes blood back into ____ circulation, as well as increased “_____” without increased ______

A

Venous beds
Central
Numbers
Volume

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59
Q

The combo of _____ of ___ mmHg and ____ position increases ICP 150%

A

IAP of 16 mmHg
Trendelenburg

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60
Q

Increased ____ pressure and impaired venous drainage of the lumbar venous plexus were causative in the reduction in the absorption of ____ during insufflation

A

IVC
CSF
[The combination of an IAP of 16 mm Hg and Tburg position increased ICP 150%.]

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61
Q

Renal vein flow, UOP, and creatinine clearance decreased more than when the IAP was greater than ____ _____

A

15 mmHg

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62
Q

Portal blood flow decreases by ____ with an IAP of 14 mmHg

A

53%

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63
Q

___ ____ also reduced total hepatic, hepatic arterial, and portal venous blood flow

A

Reverse trendelenburg

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64
Q

Splanchnic circulation decreases dependent on ____. ___ mmHg only has minimal effects, ___ mmHg mechanically compresses the mesenteric vasculature and decreases intestinal ____. _____ release causes mesenteric artery constriction.

A

IAP
7 mmHg
14 mmHg
pH
ADH

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65
Q

Physiologic changes associated with pneumoperitoneum: decreased pulm _____ - increase in peak airway pressure due to ______ shifting upward

A

Compliance
Diaphragm

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66
Q

Physiologic changes associated with pneumoperitoneum: reduced lung volumes: (4)

A
  • decreased vital capacity
  • decreased FRC
  • atelectasis
  • hypoxemia d/t vent/perf mismatching in obese/pulm disease patients (not healthy pts)
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67
Q

Physiologic changes associated with pneumoperitoneum: ______ - ____ increased 0-30% from absorption

A

Hypercarbia
CO2

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68
Q

Lap chole postop: sustained decreases in (3) for 24 hours postop

A
  • forced vital capacity
  • peak expiratory flow
  • force expiratory volume in 1 second (FEV1)

However these changes are only 50% of the changes that occur with open chole

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69
Q

Physiologic changes associated with pneumoperitoneum: CO2 Absorption - may result in ______

A

Acidosis

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70
Q

Respiratory acidosis - can increase ______ to offset

A

MV

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71
Q

Maximum absorption of CO2 at ____ ____ pressure

A

10 mmHg

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72
Q

PaCO2 reaches plateau approx. ____ ____ after start of insufflation

A

40 mins

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73
Q

Physiologic changes associated with pneumoperitoneum trendelenburg: ___-____ _____ allows small bowel and colon to move out of the pelvis and minimize needle or trocar perforation

A

10-20 degrees

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74
Q

Physiologic changes associated with pneumoperitoneum Trendelenburg: increases ____ ____ and increases ____

A

Venous return and CO

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75
Q

Physiologic changes associated with pneumoperitoneum Trendelenburg: reduces lung capacity due to weight of _____ ____ on _____ (decreased ___)

A

Abdominal contents on diaphragm (decreased FRC)

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76
Q

Physiologic changes associated with pneumoperitoneum Trendelenburg: inadvertent ____ _____ _____ intubation when the lung and carina is displaced _____

A

Right Mainstem bronchial intubation
Cephalad

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77
Q

Increased ____ _____, increased ____ _____ volume, Increased _____ increased ____ _____ work: the combo of these may lead to MI if pt is at risk

A

Venous return
Systolic heart volume
SVR
Ventricular systolic work

78
Q

Physiologic changes associated with pneumoperitoneum Trendelenburg: increase in intraabdominal pressure and gravity increase risk of ____ of ____ contents. Pts needs ____ ____.

A

Aspiration
Gastric contents
Secure airway

79
Q

Physiologic changes associated with pneumoperitoneum Trendelenburg: combined with pneumoperitoneal pressure, the t-burg position increased ____ 150% over baseline

80
Q

Increased ICP may potentially lead to ____ ____

A

Brain injury

81
Q

Physiologic changes associated with pneumoperitoneum Trendelenburg: however, if ____ ____ is suspected, the position of choice is t-burg with leaf lateral tilt ( ______ position) to prevent the bubble from traveling to the right ventricular outflow tract and causing an ______

A

Gas embolism
Durant position
Airlock

82
Q

Position of choice

A

Durant position

83
Q

Physiologic changes associated with reverse trendelenburg: (5)

A
  • allows optimum exposure and minimizes the possibility of bowel injury for some procedures
  • decreased venous return
  • decreased LVEDV
  • maintained EF in healthy pts, decreased in others
  • decreases negative pulm effects of peritoneal insufflation
84
Q

Rate of CO2 absorption is determined by: ____ _____ of the gas, the _____ ______ gradient across the membrane, and ____ ____ across the cavity

A

Tissue solubility
Diffusion pressure gradient
Blood flow

85
Q

PaCO2 will rise due to ____ ____ of _____

A

Significant amounts of absorption

86
Q

Increased absorption with extraperitoneal versus intraperitoneal due to lack of containment of ____ allowing an increased area for ____ ____

A

CO2
Gas exchange

87
Q

______ can easily occur resulting in increased catecholamines

A

Hypercarbia

88
Q

Max absorption of ____ occurs at intraabdominal pressure of ____ torr

A

CO2
10 torr

89
Q

PaCO2 levels level off ___ ____ after insufflation occurs

90
Q

Extraperitoneal can occur _____ as with lap inguinal hernia repair or _____ due to misplaced trocar

A

Purposefully
Accidentally

91
Q

EtCO2 accurately predicts changes in PaCO2 in _____, _____ _____ patients

A

Healthy, mechanically ventilated

92
Q

EtCO2 _____ increase comparably with increase in PaCO2 in patients with _____ disease

A

DOES NOT
Cardiopulmonary

93
Q

Prevent effects of Hypercarbia by controlled ____ _____ ventilation with increased _____ to decrease PaCO2 to normocarbia (target Vt __-__ ml/kg - increase ___ to maintain 35-45 mmHg PaCO2)

A

Positive pressure
MV
5-8 ml/kg
RR

94
Q

Prevent effects of Hypercarbia by minimizing SNS stimulation and ____ which would add to the increased risk of ____ ____ (premedicate with anxiolytic and use 100% O2)

A

Hypoxia
Cardiac arrhythmias

95
Q

_____ is the most widely accepted technique to lap procedures

96
Q

GA requires controlled ______, ___ ____ to minimize pulm compromise, and it alters ____ response thus spontaneous ventilation under GA results in _____

A

Ventilation
Muscle relaxant
Ventilatory
Hypercarbia

97
Q

____ NMB during lap surgeries improves the surgical space conditions when compared with _____ NMB, furthermore it also reduces postop pain scores

A

Deep
Moderate

98
Q

With regional anesthesia, studies showed no _____ due to adequate alveolar ventilation under _____ anesthesia

A

Hypercarbia
Epidural

99
Q

When regional was combined with general, there was better ___ ____ but not better ____ function

A

Pain relief
Pulm function

100
Q

LA can be performed but is ____ ____

A

Not optimal

101
Q

With the use of LA, there may be inability to ____ ____ if Hypercarbia develops, delay in treating complications, risk of injury if patient moves unexpectedly, need to ____, ____, __/___.

A

Control respiration
Explain
Anxiety
N/V

102
Q

N2O is ____

A

Controversial

103
Q

N2O is more soluble than _____ and can move into __-____ spaces faster than _____ can move out causing distention

A

Nitrogen
Air-filled
Nitrogen

104
Q

Increase of ____ ____ size after 4 hours of breathing N2O

A

Intestinal lumen

However, surgeons were unable to say if the patient was receiving N2O after 70-80 mins of a lap chole procedure

105
Q

N2O causes _____ of air embolism

106
Q

N2O causes increased ____ but no difference in ____

A

Vomiting
Nausea

107
Q

We must provide adequate ____ ____ to avoid risks of injury to organs or vessels or umbilical hernia

A

Muscle relaxation

108
Q

Evacuate any air from _____ to minimize ____ _____ and avoid risk of injury during Veress needle insertion

A

Stomach
Gastric distention

109
Q

Stop _____ during insertion of Veress needle to avoid pushing abdominal contents up toward the needle

A

Ventilation

110
Q

Explain increased risk of postop ____ and ____ with laparoscopy (48%) and use ____ _____ measures

A

Nausea and vomiting
Multimodal prophylactic measures

111
Q

Laparoscopy is less painful than ____ ____ (___ ___) but still painful

A

Open procedure (lap chole)

112
Q

Analgesia options: (5)

A
  • pre-incisional infiltration
  • intraperitoneal instillation of local (?)
  • TAP block
  • NSAIDs (talk to surgeon)
  • opioids
113
Q

Opioids induce ____ of the ____ of _____ (lap chole) and can be antagonized with ____, ____, or _____. Also causes increased __/__

A

Spasm of the sphincter of Oddi
Glucagon (1st choice), NTG, or narcan
N/V

114
Q

Deferred pain to shoulders r/t _____ of the _____, and occurrence is likely on ___ ___ post op

A

Irritation of the diaphragm
First day

115
Q

Assist the surgeon to expel as much CO2 as possible by giving ____ ____ to the patient as trocar is open at the ____ of the case

A

Deep breaths
End

116
Q

_____ and _____ can occur during the creation of the pneumoperitoneum secondary to reflex _____ stimulation from stretching and distention of peritoneum.

A

Bradycardia and asystole
Vagal

117
Q

______ arrhythmias can occur due to hypercarbia

A

Ventricular

118
Q

____ can occur due to compression of the IVC, hemorrhage, and gas embolism

119
Q

CO2 enters the circulation via ____ ____ ___

A

Open venous access (needle in a vessel, portal circulation)

120
Q

Because of solubility of ____, small amounts may be _____ without _______ (___% TEE)

A

CO2
Reabsorbed
Consequence
69% TEE

121
Q

With large amounts of CO2, embolus may form ___ ____ in the ____ atrium or ventricle to impair venous return and ____ ventricular outflow

A

Gas lock
Right
Right

122
Q

It may reach the pulm circ, cause _____ and ____ failure

123
Q

In lap chole patients, (ASA I-III) had relatively small ____ ____ detected with _____

A

CO2 emboli
TEE

124
Q

Presenting signs of CO2 embolus: (7)

A
  • hypotension
  • jugular venous distention
  • tachycardia
  • mill wheel murmur
  • rapid, but short-lived increase in EtCO2 followed by a decrease
  • hypoxemia
  • cyanosis
125
Q

For CO2 embolism, ____ insufflation and ____ peritoneum

A

Stop
Release

126
Q

Place pt in _____ position with ____ side down to prevent bubble from entering right ventricular outflow tract (____)

A

T-burg
Left
Durant

127
Q

_____ to reduce CO2 levels

A

Hyperventilate

128
Q

Insert ____ to aspirate bubble from right atrium

129
Q

Raise ____ by giving ___ volume

130
Q

Complications of laparoscopic surgery: tracking of insufflation CO2 around the ____ and ______ hiatuses of the diaphragm into the ______ and rupture of the ____ ____

A

Aortic and esophageal hiatuses
Mediastinum
Pleural space

more likely during lengthy procedures and during procedures on the lower esophagus

131
Q

Complications of laparoscopic surgery: Rupture of ____ ____ or ____

A

Lung bulla or bleb

132
Q

Complications of laparoscopic surgery: Unexplained increased airway ____, _____, severe CV compromise with _____, SC _____

A

Pressure
Hypoxemia
Hypotension
Emphysema

133
Q

Complications of laparoscopic surgery: Treatment - deflation of the ____ and ___ ___ decompression if hemodynamically unstable. Small pneumothoraces may be treated conservatively and allowed to _____

A

Abdomen and chest tube decompression
Reabsorb

134
Q

Complications of laparoscopic surgery: Pulmonary dysfunction - less than ____ ____ but still compromised. ______ dysfunction may last up to 24 hours

A

Open procedure
Diaphragmatic

Alveoli recruitment maneuver important

135
Q

Complications of laparoscopic surgery: ___ ___ ____ - compression stockings and early ambulation

A

Deep vein thrombosis

136
Q

Complications of laparoscopic surgery: ___ ___ ____ - compression stockings and early ambulation

A

Deep vein thrombosis

137
Q

Patient positioning with:
- prostatectomy: _____ ____
- pelvis: _____ with ____ ____
- hold patient’s positioning

A

Steep trendelenburg
Lithotomy with steep trendelenburg

138
Q

____ of procedure is important and so are pressure points. Caution to avoid ____ ____, _____ neuropathy, and lat fem cutaneous nerve injury

A

Length
Brachial plexus
Ulnar

139
Q

____ abrasions v. Ischemic ____ _____

A

Corneal
Optic neuropathy

140
Q

Fluid limit - __-__ ____ of crystalloid, consider colloid use

A

1-2 Liters

141
Q

Fluid restrictions to minimize ____, UOP to interfere with reanastomosis must be balanced with too ____ to cause oliguria, one suggestion is ____ ml until vesicourethral reanastomosis, then infuse ____-____ ml by end of surgery

A

Edema
Dry
800
700-1200

142
Q

Robotic assisted laparoscopic radical prostatectomy patients have mean age of ____ years old

143
Q

Robotic prostatectomy pts have increased incidence of ____ and ____ abnormalities r/t prostatic hypertrophy

144
Q

Robotic prostatectomy pts need _____ assessment and assessed for _____ ____

A

Airway
Peripheral neuropathies

145
Q

COPD pts may be difficult to _____. _____ control is better than ____ control BUT PIPs greater than __-__ cm H2O can result in barotrauma

A

Ventilate
Pressure
Volume
50-60 cm H2O

146
Q

Thoracoscopy - indicated for _____ procedures as well as operative lung ____

A

Diagnostic
Biopsies

147
Q

Thoracoscopy - patient positioned in the ____ ____ position

A

Lateral decubitis

148
Q

Thoracoscopy- ____, _____, or ____ anesthesia

A

Local, general, or regional

(Intercostal nerve block alone or with spinal or epidural block)

149
Q

Thoracoscopy - ___-___ ventilation using a ___-____ ETT placed in ____ mainstem

A

One-lung
Double-lumen
Left

150
Q

Thoracoscopy - video assisted thoracic surgery (VATS) indicated for ___ ____ and ____ ___

A

Lung nodules and pleural effusion

151
Q

Thoracoscopy - ____ resection

152
Q

Thoracoscopy - lung resections formally requiring ____ ____ ____

A

Open thoracotomy incision

153
Q

Thoracoscopy - ___ small incisions

154
Q

Thoracoscopy - ____-____ ventilation is required

155
Q

Gasless Lap - uses no ______

A

Pneumoperitoneum

156
Q

Gasless Lap - technique using _____ ____ using a _____ retractor - lifts abdominal wall __-___ cm with on lay __-__ mmHg IAP

A

Abdominal lift
Mechanical retractor
10-15 cm
1-4 mmHg

157
Q

Gasless Lap - avoid effects of CO2 insufflation and ____ ______ pressures

A

High intraabdominal

158
Q

Gasless Lap - minimal changes in ______, ____ functions, and ______ responses

A

Cardiopulmonary
Renal
Neuroendocrine

159
Q

Gasless Lap - may benefit ___ ____ and ____ patients

A

ASA III-IV

160
Q

Hysteroscopy - endoscopic exam of the _____ and _____ _____

A

Endocervix and endometrial cavity

161
Q

Hysteroscopy - cavity of uterus must be ____ with either ___ or ____ distending media

A

Distended
CO2
Liquid

162
Q

Hysteroscopy - indications (5)

A
  • diagnostics for infertility
  • abnormal uterine bleeding
  • localization of IUD
  • resection of the septae
  • adhesions or lesions
163
Q

Hysteroscopy - anesthesia - ______ block, ____, or _____ (not preferred). Limit ____ _____ intake

A

Paracervical block
Regional
general (not preferred)
IV fluid

164
Q

Resectoscope (TURP syndrome) distending media (3)

A
  • CO2
  • Hyskon (32% dextran)
  • Glycine 1.5%
165
Q

CO2 - diagnostic only due to ____ _____ with ____ causing embolism
[Resectoscope (TURP Syndrome)]

A

Open vessels with resection

166
Q

Hyskon (32% dextran) - anaphylaxis, ____ overload, pulm _____, _____ failure
[Resectoscope (TURP Syndrome)]

A

Fluid
Edema
Renal

167
Q

Glycine 1.5% - ____ overload, hypo____, hypo_____, hyper_____, hyper____
[Resectoscope (TURP Syndrome)]

A

Fluid overload
Hyponatremia
Hypoosmolality
Hyperammonaemia
Hyperglycinaemia

168
Q

Resectoscope (TURP syndrome) - close attention must be paid to ____ ____ versus ____ _____; ____ level prep and intraperitoneal if increased _____ _____ and post op

A

Volume in
Volume out
Na
Volume intake

169
Q

Resectoscope (TURP Syndrome) - ____ is metabolized into ammonia but the liver resulting in ammonia toxicity - _____, _____ changes, _____.

A

Glycine
Seizures
Mental
Lethargy

170
Q

Resectoscope (TURP syndrome) - if large volumes are absorbed, ______ ______ can occur with hypervolemia, hyponatremia, and decreased osmolarity causing _____ _____ aka TURP syndrome.

A

Osmolar hyponatremia
Cerebral edema

171
Q

Resectoscope (TURP syndrome) - can result in ____ (sys and dias), ______, CNS changes, __/__, HA, _____ and _____ - may lead to cardiac arrest

A

HTN
Bradycardia
N/V
Agitation
Lethargy

172
Q

TURP syndrome early signs and symptoms: (4)

A
  • restlessness leading to confusion
  • blurring of vision
  • HA
  • N/V
173
Q

TURP syndrome CV signs: unexplainable ____ followed by decreased _____, refractory ______, nodal/junctional rhythm, ____ changes, ____ waves, widening of _____.

A

HTN
BP
Bradycardia
ST changes
U waves
Widening of the QRS

174
Q

TURP syndrome fluid absorption: average rate of absorption is ____ml/min (>___L/hr)

A

20 ml/min
> 1 L/hr

175
Q

TURP syndrome circ overload: absorption, ___ ___ increases, ____ and ____ pressure increases, affects contractility and potentiates ______, dilutes ____ and decreases _____ pressure, fluid moves into _____ - (pulm and cerebral edema)

A

Blood volume increases
Sys/dias pressure increases
Failure
Proteins
Oncotic
Interstitial

176
Q

Prevention of TURP - use _____ anesthesia

177
Q

Prevention of TURP - Use ____ v. _____

A

Saline v. Glycine

178
Q

Prevention of TURP - minimize _____ ______ time

A

Surgical resection

179
Q

Prevention of TURP - >1 hr of surgical resection time is associated with _____ _____

A

Increased risk

180
Q

Prevention of TURP - TURP has occurred within ___ ____ of surgery time

181
Q

Prevention of TURP - Different surgical techniques such as ____ _____

A

Laser vaporization

182
Q

Prevention of TURP - ______!!!!! Increased risk with _____ ______

A

COMMUNICATION
Capsular perforation

183
Q

Prevention of TURP - If suspected, complete procedure ____, draw labs such as (4)

A

Quickly
CBC, lytes, Na, and osmolality

184
Q

Prevention of TURP - Administer ___ ____ and _____

A

Normal saline and furosemide

185
Q

Prevention of TURP - Glycine deficits of ___ mL lead to decreases in ____ of ____ mEq/L

A

500 mL
Na of 2.5 mEq/L

186
Q

Prevention of TURP - If under GA, mental status changes are ______

A

Not assessable

187
Q

Prevention of TURP - _____ anesthesia is recommended

188
Q

Prevention of TURP - Correction of Na is important as Na < ____ has increased risk of mortality. However, hypertonic saline should be given only to correct at __-___ ____. Correcting too rapidly can lead to ____ ____ ______ with paresis, mutism, pseudobulbar palsy and other neurological disorders

A

120 mEq/L
1-2 mEq/L/hr
Central pontine myelinolysis

189
Q

Endoscopy factors: (7)

A
  • NPO
  • bowel prep
  • sedation “analgesia adequate in the absence of substantial pain or grimacing”
  • airway management and patient safety
  • patient satisfaction
  • positioning
  • PONV and recovery
190
Q

Endoscopy - _____ compared with ____/____ in a community setting

A

Propofol
Midazolam/fentanyl

NUNA 692 Principles III (20 decks)

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