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AS - N931 Advanced Principles of Anesthesia > General Surgery > Flashcards

General Surgery Flashcards

1
Q

Preop Evaluation

A 
Determine medical status
Develop anesthesia plan
Review proposed plan w/ patient
PMH
Lab tests & results
Physical exam
NPO status
Choose appropriate anesthetic
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2
Q

Anesthesia GOALS

A

Patient safety
Surgeon able to perform procedure
Patient comfort

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3
Q

Ideal Anesthetic

A 
Optimal patient safety & satisfaction
Ideal operating conditions
Rapid recovery
Avoid postop SE
Cost efficient
Allow early discharge from PACU
Optimize pain control
Turnover time
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4
Q

General Anesthesia Advantages

A 
Rapid onset unconsciousness
Controlled ventilation
Allows paralysis
More safely allows to position extremities
Lower failure rate
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5
Q

General Anesthesia Disadvantages

A 
↑stress response
Full stomach = aspiration risk
Loss consciousness & protective airway reflexes
PONV
Postop sedation
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6
Q

Regional Anesthesia Advantages

A 
Maintain consciousness
Skeletal muscle relaxation
GI tract contract
↓insufflation pressure
↓stress response
Quicker recovery
Spinal - less time to perform, rapid onset sensory/motor anesthesia, less pain
Epidural - lower risk PDPH, less HoTN, catheter, postop analgesia
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7
Q

Regional Anesthesia Disadvantages

A

Occasional failure to produce adequate sensory anesthesia levels
Hypotension d/t SNS blockade (worse w/ hypovolemia)

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8
Q

Peripheral Nerve Block Advantages

A

Ideal option for superficial extremity operations
Consciousness
Protective upper airway reflexes
Isolated anesthetic effect (pulm/CV disease)

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9
Q

Peripheral Nerve Block Disadvantages

A

Unpredictable sensory & motor anesthesia
Success rate r/t provider experience (not easy on 1st attempt)
Patient cooperation

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10
Q

Positioning CV Considerations

A

Central, regional, & local anesthesia mechanisms blunt position changes effect to maintain perfusion to vital organs
Upright → supine ↑VR ↑preload/SV/CO
↑arterial BP activates afferent baroreceptors located in aorta (Vagus) & w/in carotid sinuses (Glossopharyngeal) ↓SNS outflow ↑PSNS impulses to SA node ↓HR/SV/CO
Mechanoreceptors ↓sympathetic outflow
Atrial reflexes ANP regulate renal sympathetic activity RAAS
GA, muscle relaxation, PPV, & neuraxial blockade interfere w/ VR, arterial tone, & autoregulatory mechanisms
Spinal/epidural - significant sympathectomy ↓preload & blunted cardiac responses
PPV & PEEP ↑intrathoracic pressure ↓venous pressure gradient ↓CO
Arterial BP labile after induction & positioning

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11
Q

Positioning Pulmonary Considerations

A 
Anesthesia + spontaneous ventilation ↓Vt/FRC 
Anesthesia + PPV ↓V/Q matching ↓PaO2 
- Adequate MV 
- Limited atelectasis
- PEEP

Any position that limits diaphragm, chest wall, or abdomen movement potential ↑atelectasis or intrapulmonary shunt → V/Q mismatch

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12
Q

Laparoscopic Surgeries

A 
Gastric - bypass or band
Hernia repair
Colon
Spleen
Hepatic
Appendectomy
Gallbladder
Gynecologic
Urologic
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13
Q

Laparoscopic Advantages

A

Lower pain scores & opioid requirements intra & postop
Earlier ambulation & return to normal activities
Lower incidence postop ileus (nutritional status)
Fast recovery & shorter LOS
Reduced postop pulmonary dysfunction
↓stress response
Lower cost (usually)

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14
Q

Laparoscopic Disadvantages

A 
Impaired visualization
Expensive equipment
Requires specific surgical skill
Limited ROM
Altered depth perception
No tactile sensation
↑PONV
Referred pain
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15
Q

Laparoscopic Contraindications

A 
Altered neuro status ↑ICP
Hypovolemia
VP shunt or peritoneal-jugular shunt (LeVeen)
Severe CV or pulmonary disease
Dense adhesions
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16
Q

Pneumoperitoneum

A

Abdominal (peritoneal cavity) insufflation

  • CO2
  • Inert gases
  • Gasless (more difficult surgical skill, safer for patients)
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17
Q

CO2 Pneumoperitoneum

A

CO2 more soluble in blood than air, helium, oxygen, or nitrous oxide
Easily absorbed by tissues (high blood solubility) w/ rapid elimination
Eliminated via respiration
Non-combustible
Colorless, odorless, inexpensive

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18
Q

Pneumoperitoneum Physiological Effects

A 
SNS stimulation → HTN & tachycardia
Impaired VR → HoTN
Vagal stimulation → arrhythmia & bradycardia
↓FRC ↓compliance ↑ventilatory pressures
Barotrauma or atelectasis
↓renal perfusion → RAAS activation ↑ADH
↑intra-abdominal pressure
Risk gastric regurgitation, splanchnic ischemia, embolus, extra-peritoneal CO2
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19
Q

Pneumoperitoneum ↑

A 
PaCO2
ETCO2
PAP
MAP
SVR
HR
CVP
IAP
ICP
Vd (dead space)
Regurgitation/aspiration
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20
Q

Pneumoperitoneum ↓

A 
Cardio-pulmonary function
CO
VR
FRC
VC
Renal function
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21
Q

Intra-Abdominal Pressure

A

IAP

<15mmHg to avoid CV compromise

22
Q

Re-Position →

A

CHECK ETT POSITION

23
Q

Anesthesia Maintenance

A 
Volatile anesthetic, opioids, TIVA
Avoid N2O (expands bowel lumen)
PONV risk consider Propofol TIVA
Muscle relaxation?
Monitor hemodynamic & pulmonary status
24
Q

Conversion to Open Procedure

A

Supine position
↑replacement fluid d/t 3rd space loss
New pain management plan (abdominal incision)
Change ventilator settings ↓RR/Vt/PIP/PEEP

25
Q

Gas Embolism

A 
Direct needle placement into vessel or gas insufflation into abdominal organ
Obstructs VR
Acute R ventricle hypertension = paradoxical embolism
V/Q mismatch
Hypoxemia
Sudden ↓ETCO2
Circulatory collapse
Hypotension ↑HR
Bronchospasm 
↑PIP
26
Q

Gas Embolism Treatment

A 
STOP insufflation
De-sufflate abdomen
Place patient in steep Trendelenburg & L lateral decubitus
Discontinue N2O
Admin 100% FiO2
Hyperventilate
Place CVP line & aspirate
CPR helps to break up bubbles
Consider CPB or inotropes
27
Q

Robotic-Assisted Laparoscopy Advantages

A 
3D view
Depth perception intuitive movements
↑precision 10-15x
↑magnification
Free movement - less limitations as compared to standard laparoscopic surgery
28
Q

Robotic-Assisted Laparoscopy Disadvantages

A

Massive system
Limited working space, patient access, & instrument availability
Expensive + maintenance costs
Longer setup (dock the robot)

29
Q

Cholecystectomy

A

Oddi sphincter spasm treatment - Naloxone, Glucagon, NTG
Conversion to open risk factors - acute cholecystitis, previous upper abdominal surgery, male, advanced age, obesity, bleeding, bile duct injury
Place OG/NG
Potential complications - cystic artery bleeding, cystic duct liver laceration, pneumothorax
DVT prophylaxis
Reverse Trendelenburg
L tilt (R side up)
Surgeon on patient L (supine) or b/w patient legs (lithotomy)

30
Q

Herniorrhaphy

A 
Outpatient elective surgery
Incarcerated hernia = URGENT
Strangulated = EMERGENT
- Potential necrotic bowel requiring resection ↑morbidity & mortality
Avoid strain (smooth emergence)
EBL ≈50mL
Postop pain 4-6
Bradycardia d/t peritoneal retraction
31
Q

Appendectomy

A 
Appendicitis
General anesthesia RSI
OG/NG tube
Avoid N2O
Antibiotics
Fluid & electrolyte deficits
Aspiration precautions
Avoid Metoclopramide w/ obstruction
Skeletal muscle relaxation
32
Q

Esophagogastroduodenoscopy

A

EGD
Shared airway/limited access
Mouth-piece inserted by endoscopist to prevent biting
Airway concerns consider GETA
Complications - perforation, bleeding, desaturation, laryngospasm
Supine or lateral decubitus
Notice food when scope placed abort procedure w/o secured airway

33
Q

Endoscopic Retrograde Cholangiopancreatography

A

ERCP
Diagnose & treat pancreatic/biliary disorders
Use contrast dye
30min to several hours
Complications - perforation, bleeding, desaturation, laryngospasm
L lateral decubitus or prone

34
Q

Colonoscopy

A 
Cancer screening & treat polyps
Colon prep 
Fluid & electrolyte deficits
Complications - perforation, bleeding, desaturation, laryngospasm
L lateral decubitus
35
Q

Nissen Fundoplication

A 
Laparoscopic or transthoracic (open) approach
Surgical time 3-4hr
GETA
RSI w/ cricoid pressure
H2 blockers, Metoclopramide, antibiotic, antiemetics
54-60Fr esphageal dilator
NG tube 12-24hr postop
Lithotomy & reverse Trendelenburg
Smooth extubation to prevent coughing
36
Q

Esophagectomy

A 
Double-lumen tube
Airway fire risk
Patient condition - dysphagia, malnourished, cachectic, chronic aspiration, pulmonary complications
Potential L RLN damage
Smooth emergence
Postop pain management (epidural?)
37
Q

Gastrostomy

A

GT to provide nutritional support or GI compression
Indications - dysphagia or aspiration
Laparoscopic, percutaneous, or open approach
Surgical time <1hr

38
Q

Gastrectomy

A 
Malnourished
Correct hypovolemia & anemia
Chemo/radiation
Ensure cross-matched blood available (hemorrhage risk)
Full stomach → RSI
NG tube
Awake extubation
39
Q

Small Bowel Resection

A

Healthy bowel anastomosis or ileostomy created
Bowel prep → hypovolemia & hypokalemia
Preop EKG, CBC, electrolytes, type & screen
Surgical time 2-4hr
EBL <500mL
Aspiration precautions, RSI w/ cricoid pressure, NG tube, Foley catheter, avoid Metoclopramide, postop pain management (epidural?), 3rd space fluid loss 10-15mL/kg/hr, hypothermia
Postop complications - pulmonary effusion, anastomosis leak, short bowel syndrome, sepsis, small bowel necrosis

40
Q

Colectomy

A 
Bowel prep → hypovolemia & hypokalemia
Clear liquids 1-2 days preop
IV/PO antibiotics preop
Postop thoracic epidural
Corticosteroid supplements - stress dose
41
Q

Hepatic Surgery

A

Only organ capable to regenerate functional parenchyma w/in 24hrs resection
Highly vascular - total blood flow 1.5L/min
80% blood flow supplied by portal vein
20% hepatic artery

42
Q

Liver Resection

A

CBC
PT/PTT/INR
Chemistry
LFTs
Assume full stomach (ascites, ↓gastric & intestinal motility)
Pulmonary HTN monitor CVP or PA
OG/NG tube
Potential complications:
Intraop - hemorrhage, coagulopathy, hypocalcemia, hypoglycemia, VAE, pulmonary disturbances
Postop - bleeding, bile leak, portal vein/hepatic artery thrombosis, liver failure

43
Q

Splenectomy

A

Spleen - part lymphatic system, filters foreign substances from blood & removes blood cells (sequestration), highly vascular organ 300mL/min
Only way to treat hereditary spherocytosis or splenic cancers
Trauma, abscesses, idiopathic thrombocytopenic purpura, Hodgkin’s
Splenic artery rupture (pregnancy)

Preop - evaluate underlying disease process & implications (chemo or ITP)
Intraop - asepsis, large bore IV, warming measures, epidural
Complications - atelectasis, pneumothorax, infection, hemorrhage, VAE

44
Q

Bariatric Surgery

A

Malabsorptive, restrictive, combined

Pulmonary emboli are 1° cause periop 30 day mortality
3x more frequent than anastomosis leak w/ subsequent sepsis

45
Q

Malabsorptive Procedures

A

Jejuno-ileal bypass

Biliopancreatic diversion

46
Q

Restrictive Procedures

A

Gastroplasty VBG

Adjustable gastric banding AGB

47
Q

Combined Procedures

A

Restrictive & minimal malabsorptive

Roux-en-Y gastric bypass RYGB

48
Q

Laparoscopic Bariatric Surgery Advantages

A 
Less postop pain
Lower morbidity
Quicker recovery
Less fluid 3rd spacing
↓wound infection
Smaller incisions
49
Q

Laparoscopic Bariatric Surgery Disadvantages

A

Complete NMB important
Positioning requirements ↑fall risk
High risk R mainstem intubation
Higher incidence rhabdomyolysis

50
Q

Implantable Gastric Stimulator

A

Laparoscopic placement
Stimulate gastric smooth muscle ↓peristalsis
Patient feels less hungry (theoretically)
Avoid N/V
Valsalva maneuver potential to dislodge electrodes
EKG interference

51
Q

Obese Patient Considerations

A

Pre-medication
Anxiolysis & aspiration pneumonitis precautions
IM injections unreliable - longer needles required
DVT prophylaxis
Pulmonary embolism risk → early ambulation
OSA/OHS potential difficult airway
Preop ABG
Airway assessment neck circumference = most important factor
Pre-oxygenation = most important step
↓FRC ↑O2 consumption
Higher difficult airway incidence
Awake intubation or RSI

52
Q

Thromboembolism Prevention

A

LMW heparin
- Limits postop pain management options
Preop ASA & Warfarin
Exercise, antithrombotic drugs, prophylaxis, nonpolycythemic Hct, ↑CO, early ambulation

AS - N931 Advanced Principles of Anesthesia (17 decks)

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