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Advanced Principles of Anesthesia - 931 > General Surgical Considerations > Flashcards

General Surgical Considerations Flashcards

1
Q

Advantages of General Anesthesia (5)

A
  1. rapid onset of u/c
  2. controlled ventilation
  3. paralysis
  4. positioning extremes are safer
  5. lower failure rate
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2
Q

Disadvantages of General Anesthesia (4)

A
  1. increased stress response
  2. full stomach = risk of aspiration
  3. PONV
  4. postoperative sedation
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3
Q

Advantages of Regional Anesthesia (6)

A
  1. maintenance of consciousness
  2. skeletal muscle relaxation
  3. contraction of GI
  4. lower insufflation pressure
  5. decreased stress response
  6. faster recovery
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4
Q

Spinal advantages (3)

A
  1. less time to perform
  2. rapid onset sensory/motor anesthesia
  3. less pain
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5
Q

Epidural advantages (3)

A
  1. lower risk PDPH
  2. less hypotension
  3. catheter –> postoperative analgesia
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6
Q

Disadvantages of Regional Anesthesia (2)

A
  1. occasional failure to produce adequate levels of anesthesia
  2. hypotension d/t SNS blockade (worse w/hypovolemia)
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7
Q

Peripheral Nerve Block advantages (3)

A
  1. Consciousness
  2. Protective upper airway reflexes
  3. Isolated anesthetic effect pulm/CV dx
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8
Q

Peripheral Nerve Block disadvantages (3)

A
  1. unpredictable
  2. success rate r/t provider experience
  3. need patient cooperation
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9
Q

Supine Injuries

A
  • abduction < 90 to prevent brachial plexus injury
  • supinated hand to prevent ulnar nerve injury (most common)
  • pressure alopecia
  • backache
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10
Q

Lithotomy

A
  • hips flexed 80 - 100 degrees
  • legs abducted 30 - 45
  • common peroneal nerve injury
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11
Q

Lateral decubitus

A
  • prevent lateral rotation of neck and stretch injuries to brachial plexus
  • axillary roll to avoid compression injury to dependent brachial plexus
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12
Q

Laparoscopic surgery advantages

A
  • lower pain scores & opioid requirement
  • earlier ambulation & return to normal activities
  • lower incidence of post-operative ileus
  • faster recovery, shorter LOS
  • reduced postoperative pulmonary dysfunction
  • decreased stress response
  • lower cost
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13
Q

Laparoscopic surgery disadvantages

A
  • impaired visualization
  • expensive equipment
  • requires specific surgical skill
  • limited ROM/altered depth/no tactile
  • increased PONV
  • referred pain
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14
Q

Laparoscopic c/i

A
  1. increased ICP
  2. Hypovolemia
  3. V/P shunt or periotenal-jugular shunt (LeVeen)
  4. Severe CV dx
  5. Severe respiratory disease
  6. Dense adhesions
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15
Q

What are the effects of CO2 insufflation?

A
  1. SNS = htn, tachycardia
  2. Decr. VR = hpotn
  3. vagal stimulation = arrythmia, bradycardia
  4. pulmonary complications
  5. reduced renal perfusion –> RAAS
  6. regurg/embolus/splanchnic ischemia
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16
Q

What does pneumoperitoneum do to dead space

A

increase

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17
Q

What does pneumoperitoneum do to HR

A

increase

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18
Q

Pulmonary Management (4)

A
  1. position changes
  2. vent settings
  3. increase VA
  4. bronchodilators
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19
Q

CV Management (3)

A
  1. slow, gradual insufflations
  2. vent if IAP > 20 mm Hg
  3. evaluate intravascular volume
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20
Q

Renal/Hepatic Management (4)

A
  1. monitor UOP
  2. IVF bolus
  3. consider diuretics
  4. Maintain IAP < 15
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21
Q

CBF (2)

A
  1. decrease T-Burg

2. Vent abdomen if IAP > 20 mmHg

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22
Q

Ventilation goals

A

etco2 = 35 mmHg, PIP low 30s cm H2O

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23
Q

What is the downside of proseal LMA?

A

can’t secure airway, control ventilation, or give paralytic

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24
Q

Positioning for lap case

A

tilt to not exceed 15 - 20 degrees
make changes slowly & recheck ETT after every position
wait to replace fluid until end

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25
Cardiac Tx for Increased Vagal Tone
1. tell surgeon to deflate 2. atropine 3. if pt stable, deepen anesthetic 4. insufflate slowly
26
Capnothorax tx
1. deflate 2. supportive 3. PEEP if not trauma present
27
CO2 embolus s/s
-tachycardia, arrhythmia, HoTN, millwheel murmur, increased CVP cyanosis and drop in ETCO2 & bronchospasm
28
CO2 embolus tx
``` release insufflation LLD 100% oxygen Hyperventilate Place CVP ```
29
SQ Emphysema physiology
accidental insufflation of extraperitoneum
30
SQ Emphysema s/s posop
increase HR/BP | somnolence or resp. acidosis
31
Laparoscopic Pain
shoulder pain (irritation of diaphragm and/or visceral pain from biliary spasm) tx: opioids + NSAIDS + acetaminophen + LA
32
Lap PONV
40 - 75%
33
Robotic Assisted Laparoscopy Advantages
1. 3d view (good depth perception) 2. precision increased 10 - 15x 3. magnification increased 4. free movement
34
Robotic Assisted Laparoscopy Disadvantages
1. massive system 2. limited working space 3. limited patient access 4. limited instrument availability 5. expensive 6. maintenance costs 7. long setup
35
Robot surgery PREP
2 PIVs + A-Line Limit IVF initially Positioning: TBURG, Lateral, Flexion
36
Name 3 reasons for cholecystectomy
1. cholecystitis 2. cholelithiasis 3. cancer
37
What is herniorrhaphy?
Defect in muscles of abdominal wall | inguinal, umbilical, incisional, abdominal, femoral, diaphragmatic
38
Why do they perform appendectomy?
obstruction/inflammation d/t lymphoid tissue or fecal matter
39
How to treat sphincter of oddi spasm?
naloxone, nitro, glucagon
40
Rate of conversion for cholecystectomy?
5-10%
41
Some risk factors for conversion of chole?
``` acute cholecystitits w/thickened gallbladder wall previous abdomen surgery male gender old & obese bleeding or bile duct injury ```
42
Potential complications of cholecystectomy
bleeding from cystic artery & cystic duct liver lac | pneumo
43
Cholecystectomy positioning (3)
1. Surgeon on patient's left (supine) 2. lithotomy 3. reverse Tburg tilt left (rt side up)
44
Anesthetic choice for herniorrhaphy
GA, local, regional (T8)
45
EBL for herniorrhaphy
50 mL
46
Postop pain for heniorrhaphy
4-6 | LA infiltration of ilioinguinal & iliohypogastric nerves
47
Technique for appendectomy
GA (RSI), OGT avoid N2O & reglan need abx & relaxation
48
Esophagogastroduodenoscopy
conscious sedation/topical, GA shared airway/limited access mouth-piece inserted by endoscopist to prevent biting consider GETA (obese, RF)
49
EGD/colonscopy complications
perforation bleeding desaturation laryngospasm
50
EGD/colonoscopy position
supine or lateral decubitus
51
Colonoscopy reasoning
view lining of rectum & colon for 1. CA screening 2. tx polyps
52
Colonoscopy positioning
LLD | heavy sedation btw or GA
53
Colonoscopy complications
perforation bleeding desaturation laryngospasm
54
Endoscopic retrograde cholangiopancreatography (ERCP)
dx and treat pancreatic & biliary disorders | contrast dye is used
55
ERCP position
LLD prone may change
56
ERCP length
30m- hours
57
ERCP type of anesthesia
GETA or sedation
58
ERCP complications
perforation bleeding laryngospasm & or desaturation
59
Esophageal surgery indications
GERD CA Hiatal hernia Motility d/o
60
Esophageal surgery pt s/s
dysphagia heartburn hoarse voice chest pain
61
Nissen fundoplication
fundus wrapped around lower esophagus and sutured to reinforce lower esophageal sphincter
62
Nissen fundoplication surgical approach
- lap or open - GETTA, RSI - you will be asked to place a large bougie down esophagus, lubricate it!! bougie distends the esophagus and aids the assessment of fundoplication & hiatus *DO NOT FORCE IT*
63
Nissen fundoplication time
3 - 4hours
64
Meds for nissen fundoplication
H2 blockers (famotidine 20 mg) metoclopramide 2-4 h preop (0.1 - 0.25 mg/kg) ABC ANTIEMETICS - very important to prevent retching
65
Nissen positioning
lithotomy and reverse T burg
66
Nissen f. materials
OGT initially to decompress, then remove NGT 12 - 24h postop 54 - 60 Fr esophageal dilator (Bougie)
67
Esophagectomy
majority of thoracic esophagus & nearby lymph nodes removed stomach moved up & attached to remaining portion of esophagus
68
Esophagectomy hx
ETOH, tobacco, chemo/radiation
69
Esophagectomy anesthesia considerations
surgical approach invasive monitors double-lumen tube posop pain
70
Esophagectomy materials
``` bare hugger + fluid warmer invasive monitors (A-Line for sure) ```
71
Esophagectomy pearls
- duration 3 - 8h - preop bowel prep likely - preop reglan helfpul - many different surgical approaches - pt will be supine w/head turned (rlly tape the ett good)
72
Gastrostomy
create an opening through the skin & the stomach wall to provide nutritional support or GI compression
73
Gastrostomy indications
dysphagia, aspiration
74
Gastrostomy appraoch
lap/peg/or open
75
Gastrostomy time
< 1 h (GA + RSI indicated or LA + sedation)
76
Gastrectomy considerations
``` chemo/radiation cross match blood available full stomach/ngt invasive monitoring warming extubate awake anticipate large fluid shifts ```
77
intestinal surgery
diverticulitis CA crohn's UC
78
Small bowel resection
bowel prep so | EKG, CBC, lytes, T&S
79
SBR time
2-4 h | EBL < 500 mL
80
SBR anesthesia considerations
``` aspiration- RSI NGT foley AVOID REGLAN! consider epidural third space 10 - 15 mL/kg/hr Hypothermia ```
81
colectomy
``` open or lap volume depleted thoracic epidrual for postop pain ask surgeon what abx they want may need to supplement steroids ```
82
hepatic surgery (blood flow considerations)
HIGHLY VASCULAR 1.5 L/m 80% supplied by portal vein 20% hepatic artery
83
liver resection preop work-up
CT/MRI for tumor location 12 lead EKG/echo CXR CBC/PT/PTT/bldg time, CMP, LFTs
84
optimize your liver patient
Vit K, recombinant factor 7 or FFP in emergency | consider plt infusion if < 100k
85
liver patient stomach considerations
assume full stomach (ascites, decreased motility) | H2 blocker, reglan, sodium citrate
86
liver resection monitoring
a-line CVP or PA if pulmonary HTN TEG to guide blood product admin foley
87
liver resection intraop
local/mac (adequate sedation to minimize SNS) | GETA (RSI)
88
liver resection & drug alterations
benzo - decreased clearance, prolonged half life dex - same ^ propofol - one dose is normal response, recovery times longer after infusions
89
liver dx & meperidine
neurotoxicity d/t doubling of half life | exaggerated sedative and resp. depression
90
liver dx & sufentanil
PK not altered rly
91
liver dx & alfentanil
e1/2 doubled
92
nmbd & liver dx
increased volume of distribution may require a higher initial dose
93
panc/vec/roc & liver dx
prolonged DOA
94
cisatracurium & liver dx
wnl
95
sux & liver dx
prolonged
96
catecholamines & liver dx
decreased response d/t circulating vasodilators such as bile acids & glucagon impaired ability to translocate blood from pulmonary and splanchnic reservoirs use non adrenergic vasopressor (vasopressin) biliary obstructed pt very intolerant of blood loss
97
intraop fluid management liver resection
CVP < 5 cm H2O
98
what does the spleen do
lymphatic system 1. filters foreign substances & removes blood 2. regulates Q to liver; sequestration 3. very vascular (300 mL/m)
99
splenectomy open/lap
indications: trauma, abscess, CA, ITP, hodgkin's staging
100
bariatric surgery pt BMI
> 40 kg/m2 > 35 kg/m2 w/co-morbidities not controlled can be done via laparoscopically, but if > 180 kg will be done open
101
malabsorptive procedures
jejunoileal bypass and biliopancreatic diversion
102
restrictive procedures
gastroplasty (VBG) - pouch created to communicate w/stomach | adjustable gastric banding (AGB)
103
combined restrictive & malabsorptive
roux-en-y gastric bypass (RYGB) most common anastomosing proximal gastric pouch to proximal jejunum
104
lap bariatric surgery advantages
``` less pain lower morbidity faster recovery less 3rd spacing decreased infection ```
105
lap bariatric sx disadvantages
complete nmb necessary positioning requirements increase the fall risk high risk for rt main stem rhabdo is higher
106
anesthesia considerations for gastric stimulator
valsava will dislodge electrodes | ekg interference
107
or table max weight
200 kg
108
mortality in 20 day periop period for bariatric sx d/t
PE preop aspirin & warfarin to INR 2.3
109
obesity & fluid balance
greater blood loss d/t technical difficulties decreased ability to compensate for blood loss - thus, early threshold for replacement

Advanced Principles of Anesthesia - 931 (3 decks)

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