Exam II Anesthesia for Laparoscopic Endoscopic Procedures Flashcards by Linsley Lloyd

Advantages of laparoscopic procedures (7)

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

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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Lap absolute contraindications (6)

bowel obstruction
ileus
peritonitis
intraperitoneal hemorrhage
diaphragmatic hernia
severe cardiopulmonary disease (CHF)

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Lap relative CIs: (8)

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

Pelvis
First trimester
Umbilicus

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The enlarged uterus after the ____ week interferes with _____

23rd
Visualization

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

PaCO2
Alkalotic

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Place pregnant patient in ____-_____ _____-______ displacement

30-degree
Left-uterine

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Limit intraperitoneal pressures in pregnant women to ____ ____

12 mmHg

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Monitor fetal ____ ____ throughout with ______ ultrasound

Heart rate
Transvaginal

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

Creation of the pneumoperitoneum
Potential for systemic absorption of CO2
Initial trendelenburg position
Reverse trendelenburg position

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What is a pneumoperitoneum?

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

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

Helium and argon

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____ is the safest gas to use with pneumoperitoneum

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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Characteristics of pneumoperitoneum: doesn’t support ______

Combustion

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

Tissue diffusion
Gas emboli

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Characteristics of pneumoperitoneum: More pain due to _______ irritation

Diaphragmatic

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Characteristics of pneumoperitoneum: Hyper_____, _____ acidosis, cardiac ______

Hypercarbia
Respiratory acidosis
Cardiac dysrhythmias

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

Abdominal wall
Contents
Visualization

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

Movement
Instruments
CO2

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

Umbilical

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

Veress needle

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

19 mmHg (3L)

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

Automatic mode
12 mmHg

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

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

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

Lumbodorsay lascia 15-20 mmHg

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

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

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

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

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

50%

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

Aren’t 3.5-5%

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

Penetration of vessels Rupture of spleen

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

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

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

Urinary tract

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

Methylene blue Blood

Risk factors for injuries during pneumoperitoneum: (7)

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

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

Subcutaneous emphysema

Subcutaneous emphysema can cause ____ issues

Airway

With SC emphysema, consider leaving patient ____ until _____

Intubated Reabsorbed

Physiologic changes associated with pneumoperitoneum depend on: (8)

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

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

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

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

Other factors Position

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

IA pressure

Initially CVP increases due to to _____ of abdominal _____ _____

Redistribution Blood volume

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

Venous return Thorax cavity Volume

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

Vasopressin (ADH) Catecholamines

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

20 torr v. 10 torr

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

Venous return Pneumo Reverse trendelenburg

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

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]

16 20

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]

Legs are wrapped Normovolemic

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

Venous return

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

- perioperative hydration - changes in pt position - compression stockings

______ with initial insufflation [Physiologic changes associated with pneumoperitoneum]

Bradycardia

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

Prolonged QT

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

Filling pressures Preload (decreased venous return)

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

Cerebral Intracranial

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

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

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

Venous beds Central Numbers Volume

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

IAP of 16 mmHg Trendelenburg

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

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

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

15 mmHg

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

53%

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

Reverse trendelenburg

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

IAP 7 mmHg 14 mmHg pH ADH

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

Compliance Diaphragm

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

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

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

Hypercarbia CO2

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

- 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

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

Acidosis

Respiratory acidosis - can increase ______ to offset

Maximum absorption of CO2 at ____ ____ pressure

10 mmHg

PaCO2 reaches plateau approx. ____ ____ after start of insufflation

40 mins

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

10-20 degrees

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

Venous return and CO

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

Abdominal contents on diaphragm (decreased FRC)

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

Right Mainstem bronchial intubation Cephalad

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

Venous return Systolic heart volume SVR Ventricular systolic work

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

Aspiration Gastric contents Secure airway

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

ICP

Increased ICP may potentially lead to ____ ____

Brain injury

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 ______

Gas embolism Durant position Airlock

Position of choice

Durant position

Physiologic changes associated with reverse trendelenburg: (5)

- 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

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

Tissue solubility Diffusion pressure gradient Blood flow

PaCO2 will rise due to ____ ____ of _____

Significant amounts of absorption

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

CO2 Gas exchange

______ can easily occur resulting in increased catecholamines

Hypercarbia

Max absorption of ____ occurs at intraabdominal pressure of ____ torr

CO2 10 torr

PaCO2 levels level off ___ ____ after insufflation occurs

40 mins

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

Purposefully Accidentally

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

Healthy, mechanically ventilated

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

DOES NOT Cardiopulmonary

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)

Positive pressure MV 5-8 ml/kg RR

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

Hypoxia Cardiac arrhythmias

_____ is the most widely accepted technique to lap procedures

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

Ventilation Muscle relaxant Ventilatory Hypercarbia

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

Deep Moderate

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

Hypercarbia Epidural

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

Pain relief Pulm function

LA can be performed but is ____ ____

Not optimal

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 ____, ____, __/___.

Control respiration Explain Anxiety N/V

N2O is ____

Controversial

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

Nitrogen Air-filled Nitrogen

Increase of ____ ____ size after 4 hours of breathing N2O

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

N2O causes _____ of air embolism

Expansion

N2O causes increased ____ but no difference in ____

Vomiting Nausea

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

Muscle relaxation

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

Stomach Gastric distention

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

Ventilation

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

Nausea and vomiting Multimodal prophylactic measures

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

Open procedure (lap chole)

Analgesia options: (5)

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

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

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

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

Irritation of the diaphragm First day

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

Deep breaths End

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

Bradycardia and asystole Vagal

______ arrhythmias can occur due to hypercarbia

Ventricular

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

PEA

CO2 enters the circulation via ____ ____ ___

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

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

CO2 Reabsorbed Consequence 69% TEE

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

Gas lock Right Right

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

PHTN RH

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

CO2 emboli TEE

Presenting signs of CO2 embolus: (7)

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

For CO2 embolism, ____ insufflation and ____ peritoneum

Stop Release

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

T-burg Left Durant

_____ to reduce CO2 levels

Hyperventilate

Insert ____ to aspirate bubble from right atrium

CVL

Raise ____ by giving ___ volume

CVP IV

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

Aortic and esophageal hiatuses Mediastinum Pleural space more likely during lengthy procedures and during procedures on the lower esophagus

Complications of laparoscopic surgery: Rupture of ____ ____ or ____

Lung bulla or bleb

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

Pressure Hypoxemia Hypotension Emphysema

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

Abdomen and chest tube decompression Reabsorb

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

Open procedure Diaphragmatic Alveoli recruitment maneuver important

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

Deep vein thrombosis

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

Deep vein thrombosis

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

Steep trendelenburg Lithotomy with steep trendelenburg

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

Length Brachial plexus Ulnar

____ abrasions v. Ischemic ____ _____

Corneal Optic neuropathy

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

1-2 Liters

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

Edema Dry 800 700-1200

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

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

CAD Renal

Robotic prostatectomy pts need _____ assessment and assessed for _____ ____

Airway Peripheral neuropathies

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

Ventilate Pressure Volume 50-60 cm H2O

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

Diagnostic Biopsies

Thoracoscopy - patient positioned in the ____ ____ position

Lateral decubitis

Thoracoscopy- ____, _____, or ____ anesthesia

Local, general, or regional (Intercostal nerve block alone or with spinal or epidural block)

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

One-lung Double-lumen Left

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

Lung nodules and pleural effusion

Thoracoscopy - ____ resection

Wedge

Thoracoscopy - lung resections formally requiring ____ ____ ____

Open thoracotomy incision

Thoracoscopy - ___ small incisions

Thoracoscopy - ____-____ ventilation is required

One-lung

Gasless Lap - uses no ______

Pneumoperitoneum

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

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

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

High intraabdominal

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

Cardiopulmonary Renal Neuroendocrine

Gasless Lap - may benefit ___ ____ and ____ patients

ASA III-IV

Hysteroscopy - endoscopic exam of the _____ and _____ _____

Endocervix and endometrial cavity

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

Distended CO2 Liquid

Hysteroscopy - indications (5)

- diagnostics for infertility - abnormal uterine bleeding - localization of IUD - resection of the septae - adhesions or lesions

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

Paracervical block Regional general (not preferred) IV fluid

Resectoscope (TURP syndrome) distending media (3)

- CO2 - Hyskon (32% dextran) - Glycine 1.5%

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

Open vessels with resection

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

Fluid Edema Renal

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

Fluid overload Hyponatremia Hypoosmolality Hyperammonaemia Hyperglycinaemia

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

Volume in Volume out Na Volume intake

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

Glycine Seizures Mental Lethargy

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

Osmolar hyponatremia Cerebral edema

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

HTN Bradycardia N/V Agitation Lethargy

TURP syndrome early signs and symptoms: (4)

- restlessness leading to confusion - blurring of vision - HA - N/V

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

HTN BP Bradycardia ST changes U waves Widening of the QRS

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

20 ml/min > 1 L/hr

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

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

Prevention of TURP - use _____ anesthesia

Regional

Prevention of TURP - Use ____ v. _____

Saline v. Glycine

Prevention of TURP - minimize _____ ______ time

Surgical resection

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

Increased risk

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

15 mins

Prevention of TURP - Different surgical techniques such as ____ _____

Laser vaporization

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

COMMUNICATION Capsular perforation

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

Quickly CBC, lytes, Na, and osmolality

Prevention of TURP - Administer ___ ____ and _____

Normal saline and furosemide

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

500 mL Na of 2.5 mEq/L

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

Not assessable

Prevention of TURP - _____ anesthesia is recommended

Regional

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

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

Endoscopy factors: (7)

- 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

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

Propofol Midazolam/fentanyl