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N931 Advanced Principles > General Surgery > Flashcards

General Surgery Flashcards

1
Q

What are different types/categories of “general surgery”? (10)

A 
esophagus
stomach
intestines/colon
liver
gall bladder
pancreas
thyroid
skin
hernias
breasts
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2
Q

Common problems associated with GI diagnoses (8)

A 
fluid/electrolyte disorders
anemia
cancer
obesity
GERD
pain
nausea/vomiting
ascites
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3
Q

Advantages of general anesthesia for general surgery:

A

Allows paralysis
More safely allows positioning extremes
More reliable
lower failure rate

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4
Q

Disadvantages of general anesthesia for general surgery:

A

Increased stress response, Known full stomach= increased risk
for aspiration
More PON and sedation

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5
Q

Advantages of regional anesthesia for general surgery

A

Requires lower insufflation pressures, Patient breathes

spontaneously, Decreased stress response, Faster recovery period`

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6
Q

Disadvantages of regional anesthesia for general surgery

A

Occasional failure

Sympathectomy

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7
Q

Advantages of MAC/IV sedation for general surgery

A

Combined with local anesthesia…
Patient breathes spontaneously
Patient comfort levels

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8
Q

What things should be considered in anesthetic management? (10)

A
  1. choice of anesthetic
  2. monitors
  3. foley
  4. cuffed ETT
  5. pneumoperitoneum
  6. evacuation of GI contents
  7. positioning
  8. smooth emergence/extubation
  9. antiemetics
  10. pain management
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9
Q

What is laparoscopic surgery used for?

A

diagnostic & surgical intervention

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10
Q

What are the two methods of insufflation?

A
  1. trocar

2. Veress needle insertion

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11
Q

Compared with open surgery, laparoscopic surgery is associated with:

A
  • lower pain scores
  • lower opioid requirement
  • early ambulation
  • less post op ileus
  • faster recovery / shorter hospital stay
  • reduced pulmonary dysfunction
  • less stress response
  • less wound complications
  • lower cost
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12
Q

Disadvantages of laparoscopic technique:

A
  • impaired visualization
  • expensive equipment
  • requires specific surgical skill
  • limited range of motion/altered depth perception
  • no tactile sensation
  • increased PONV
  • referred pain
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13
Q

Six relative contraindications of laparoscopic surgery:

A
  1. increased ICP
  2. hypovolemia
  3. VP shunt or peritoneojugular shunt (OK if unidirectional valve is present)
  4. severe CV disease
  5. severe respiratory disease
  6. dense adhesions
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14
Q

What gases are used for insufflation of the abdomen?

A
  1. CO2 (choice of gas)
  2. inert gases
  3. gasless laparoscopy
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15
Q

Six relative contraindications of laparoscopic surgery:

A
  1. increased ICP
  2. hypovolemia
  3. VP shunt or peritoneojugular shunt (OK if unidirectional valve is present)
  4. severe CV disease
  5. severe respiratory disease
  6. dense adhesions
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16
Q

Why is CO2 the gas of choice in pneumoperitoneum?

A
  • CO2 is MORE soluble in blood than air, helium, oxygen, or nitrous oxide
  • CO2 is non-combustible

meaning more easily absorbed & rapidly eliminated through respiration

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17
Q

Insufflation can cause what kind of stimulation?

A

sympathetic stimulation

HTN (initial)

Vagal stimulation

bradycardia, arrhythmia

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18
Q

How does insufflation affect venous return?

A

decreases venous return = hypotension

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19
Q

How does insufflation affect the respiratory system?

A 
reduced FRC
reduced compliance
increased ventilatory pressures
barotrauma
atelectasis
20
Q

How does insufflation affect the renal system?

A
  • reduced renal perfusion
  • activation of RAAS
  • increased ADH
21
Q

How does insufflation affect the GI system?

A
  • increased intra-abdominal pressures
  • increased risk of gastric regurgitation
  • splanchnic ischemia
  • CO2 embolus
  • extraperitoneal spread of CO2
22
Q

What are the increased physiological effects of insufflation?

A
  • PaCO2
  • ETCO2
  • PAP (peak airway pressures)
  • MAP (mean arterial pressure)
  • SVR (systemic vascular resistance)
  • HR (heart rate)
  • CVP (central venous pressure
  • IAP (intraabdominal pressure)
  • ICP (intracranial pressure)
  • Vd (Dead space)
  • Risk of regurgitation/aspiration
23
Q

What are the decreased physiological effects of insufflation?

A
  • Cardiopulmonary function
  • cardiac output
  • Venous return
  • Functional residual capacity
  • Vital capacity
  • Renal function
24
Q

How are the pulmonary physiological effects of insufflation/laparoscopic surgery managed?

A
  • Position changes (decrease degree of Trendelenburg)
  • Modify
    ventilatory settings (pressure control)
  • Use PEEP with caution
  • Consider increasing volatile
  • Consider bronchodilators
25
Q

How are the cardiovascular physiological effects of insufflation/laparoscopic surgery managed?

A
  • Slow, gradual abdominal insufflations
  • Vent abdomen if IAP>20 mm Hg
  • Evaluate intravascular volume (consider IVF bolus)
  • Consider
    treatment for preexisting cardiac dysfunction
26
Q

How are the renal/hepatic effects of insufflation/laparoscopic surgery managed?

A
  • Closely monitor hourly UOP
  • Administer IVF boluses
  • Consider diuretics
  • Maintain IAP <15 mm Hg
27
Q

How are the cerebral blood flow effects of insufflation/laparoscopic surgery managed?

A
  • Decrease degree of Trendelenburg (adjust head up)

- Vent abdomen if IAP>20 mm Hg

28
Q

How are the cerebral blood flow effects of insufflation/laparoscopic surgery managed?

A
  • Decrease degree of Trendelenburg (adjust head up)

- Vent abdomen if IAP>20 mm Hg

29
Q

To use regional anesthesia for laparoscopic surgery, where does the block need to be located?

A

T4-5 (to achieve SNS denervation)

→ this makes CV compensation more difficult

30
Q

What is the intra-abdominal pressure limit?

A

15mmHg

31
Q

What are the 2 indicators of needing invasive monitoring during laparoscopic surgery?

A
  1. ASA 3-4

2. abnormal PaCO2:ETCO2 gradient

32
Q

What ventilator setting adjustments often need to be made in laparoscopic surgeries?

A
  1. Mv needs to be increased
  2. PIP increased
  3. Adjust RESPIRATORY RATE
33
Q

What is goal ETCO2 in laparoscopic surgery?

A

35mmHg

34
Q

What is the goal PIP in laparoscopic surgery?

A

PIP low 30scmH2O

35
Q

What is the goal PIP in laparoscopic surgery?

A

PIP low 30scmH2O

36
Q

What are 5 benefits of using an LMA vs ETT?

A
  1. Spontaneous ventilation
  2. Lower incidence of sore throat
  3. Lower pain scores
  4. Less analgesia required
  5. Less PONV
37
Q

What are 3 disadvantages of using an LMA vs ETT during general laparoscopic surgery?

A
  1. Unsecured airway
  2. Uncontrolled ventilation
  3. Unable to use muscle relaxant
38
Q

What are 4 positioning considerations of general laparoscopic surgery?

A
  1. Prevent nerve injury
    – common peroneal nerve (lithotomy),
    – branchial plexus (shoulder braces, etc.)
  2. Tilt not to exceed 15-20 degrees
  3. Make changes slowly
  4. Recheck the ETT position after every position change
    Watch for endobronchial intubation
39
Q

What should you consider with head down positioning?

A

Less aggressive fluid replacement d/t edema formation in the airway

40
Q

If a patient has PONV, what type of GA management during laparoscopic surgery should be considered?

A

TIVA

41
Q

What type of manienance should be used during general laparoscopic surgery?

A

Balanced surgery using volatile, opioids, or TIVA

DO NOT USE N2O

42
Q

What are 4 considerations when transitioning fro laparoscopic to open procedures?

A
  1. Reposition to supine
  2. New fluid plan d/t increased 3rd space losses
  3. Opioid requirements will increase (new pain management plan
  4. New ventilator settings (dec rate, increase Vt)
43
Q

What are 6 types of intraoperative complications that can occur during laparoscopic surgery?

A
  1. Vascular injury
  2. GI
  3. Cardiac
  4. SQ emphysema
  5. Capno-thorax, mediastinum, pericardium
  6. CO2 embolism
44
Q

Gas embolism diagnostic tools in the ideal world

A
  • Trans-esophageal echo (TEE)
    – Swan-Ganz Catheter
    – Precordial Dopplers
45
Q

Gas embolism diagnostics in the real world

A 
– Pulse oximetry (hypoxemia)
– Esophageal stethoscope-millwheel sound
– Sudden ETCO2 decrease
– Aspiration of gas from CVP
– Hypotension
– Bronchospasm
– Increased PIP
46
Q

What are vascular injuries that can occur during general/laparoscopic surgery?

A

trocar insertion/veress needle;

aorta, ICV, iliac vessels, cystic/hepatic arteries, retroperitoneal hematoma

47
Q

What are GI injuries that can occur during general/laparoscopic surgery?

A

bowel, liver, spleen, mesenteric

N931 Advanced Principles (3 decks)

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