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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
Q

Cardiac Tx for Increased Vagal Tone

A
  1. tell surgeon to deflate
  2. atropine
  3. if pt stable, deepen anesthetic
  4. insufflate slowly
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26
Q

Capnothorax tx

A
  1. deflate
  2. supportive
  3. PEEP if not trauma present
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27
Q

CO2 embolus s/s

A

-tachycardia, arrhythmia, HoTN, millwheel murmur, increased CVP
cyanosis and drop in ETCO2 & bronchospasm

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28
Q

CO2 embolus tx

A 
release insufflation
LLD
100% oxygen
Hyperventilate
Place CVP
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29
Q

SQ Emphysema physiology

A

accidental insufflation of extraperitoneum

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30
Q

SQ Emphysema s/s posop

A

increase HR/BP

somnolence or resp. acidosis

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31
Q

Laparoscopic Pain

A

shoulder pain (irritation of diaphragm and/or visceral pain from biliary spasm)

tx: opioids + NSAIDS + acetaminophen + LA

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32
Q

Lap PONV

A

40 - 75%

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33
Q

Robotic Assisted Laparoscopy Advantages

A
  1. 3d view (good depth perception)
  2. precision increased 10 - 15x
  3. magnification increased
  4. free movement
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34
Q

Robotic Assisted Laparoscopy Disadvantages

A
  1. massive system
  2. limited working space
  3. limited patient access
  4. limited instrument availability
  5. expensive
  6. maintenance costs
  7. long setup
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35
Q

Robot surgery PREP

A

2 PIVs + A-Line
Limit IVF initially
Positioning: TBURG, Lateral, Flexion

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36
Q

Name 3 reasons for cholecystectomy

A
  1. cholecystitis
  2. cholelithiasis
  3. cancer
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37
Q

What is herniorrhaphy?

A

Defect in muscles of abdominal wall

inguinal, umbilical, incisional, abdominal, femoral, diaphragmatic

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38
Q

Why do they perform appendectomy?

A

obstruction/inflammation d/t lymphoid tissue or fecal matter

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39
Q

How to treat sphincter of oddi spasm?

A

naloxone, nitro, glucagon

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40
Q

Rate of conversion for cholecystectomy?

A

5-10%

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41
Q

Some risk factors for conversion of chole?

A 
acute cholecystitits w/thickened gallbladder wall
previous abdomen surgery
male gender
old & obese
bleeding or bile duct injury
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42
Q

Potential complications of cholecystectomy

A

bleeding from cystic artery & cystic duct liver lac

pneumo

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43
Q

Cholecystectomy positioning (3)

A
  1. Surgeon on patient’s left (supine)
  2. lithotomy
  3. reverse Tburg tilt left (rt side up)
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44
Q

Anesthetic choice for herniorrhaphy

A

GA, local, regional (T8)

45
Q

EBL for herniorrhaphy

A

50 mL

46
Q

Postop pain for heniorrhaphy

A

4-6

LA infiltration of ilioinguinal & iliohypogastric nerves

47
Q

Technique for appendectomy

A

GA (RSI), OGT
avoid N2O & reglan
need abx & relaxation

48
Q

Esophagogastroduodenoscopy

A

conscious sedation/topical, GA
shared airway/limited access
mouth-piece inserted by endoscopist to prevent biting
consider GETA (obese, RF)

49
Q

EGD/colonscopy complications

A

perforation
bleeding
desaturation
laryngospasm

50
Q

EGD/colonoscopy position

A

supine or lateral decubitus

51
Q

Colonoscopy reasoning

A

view lining of rectum & colon for

  1. CA screening
  2. tx polyps
52
Q

Colonoscopy positioning

A

LLD

heavy sedation btw or GA

53
Q

Colonoscopy complications

A

perforation
bleeding
desaturation
laryngospasm

54
Q

Endoscopic retrograde cholangiopancreatography (ERCP)

A

dx and treat pancreatic & biliary disorders

contrast dye is used

55
Q

ERCP position

A

LLD
prone
may change

56
Q

ERCP length

A

30m- hours

57
Q

ERCP type of anesthesia

A

GETA or sedation

58
Q

ERCP complications

A

perforation
bleeding
laryngospasm & or desaturation

59
Q

Esophageal surgery indications

A

GERD
CA
Hiatal hernia
Motility d/o

60
Q

Esophageal surgery pt s/s

A

dysphagia
heartburn
hoarse voice
chest pain

61
Q

Nissen fundoplication

A

fundus wrapped around lower esophagus and sutured to reinforce lower esophageal sphincter

62
Q

Nissen fundoplication surgical approach

A
  • 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
Q

Nissen fundoplication time

A

3 - 4hours

64
Q

Meds for nissen fundoplication

A

H2 blockers (famotidine 20 mg)
metoclopramide 2-4 h preop (0.1 - 0.25 mg/kg)
ABC
ANTIEMETICS - very important to prevent retching

65
Q

Nissen positioning

A

lithotomy and reverse T burg

66
Q

Nissen f. materials

A

OGT initially to decompress, then remove
NGT 12 - 24h postop
54 - 60 Fr esophageal dilator (Bougie)

67
Q

Esophagectomy

A

majority of thoracic esophagus & nearby lymph nodes removed

stomach moved up & attached to remaining portion of esophagus

68
Q

Esophagectomy hx

A

ETOH, tobacco, chemo/radiation

69
Q

Esophagectomy anesthesia considerations

A

surgical approach
invasive monitors
double-lumen tube
posop pain

70
Q

Esophagectomy materials

A 
bare hugger + fluid warmer
invasive monitors (A-Line for sure)
71
Q

Esophagectomy pearls

A
  • 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
Q

Gastrostomy

A

create an opening through the skin & the stomach wall to provide nutritional support or GI compression

73
Q

Gastrostomy indications

A

dysphagia, aspiration

74
Q

Gastrostomy appraoch

A

lap/peg/or open

75
Q

Gastrostomy time

A

< 1 h (GA + RSI indicated or LA + sedation)

76
Q

Gastrectomy considerations

A 
chemo/radiation
cross match blood available
full stomach/ngt
invasive monitoring
warming
extubate awake
anticipate large fluid shifts
77
Q

intestinal surgery

A

diverticulitis
CA
crohn’s
UC

78
Q

Small bowel resection

A

bowel prep so

EKG, CBC, lytes, T&S

79
Q

SBR time

A

2-4 h

EBL < 500 mL

80
Q

SBR anesthesia considerations

A 
aspiration- RSI
NGT
foley
AVOID REGLAN!
consider epidural
third space 10 - 15 mL/kg/hr
Hypothermia
81
Q

colectomy

A 
open or lap
volume depleted
thoracic epidrual for postop pain
ask surgeon what abx they want
may need to supplement steroids
82
Q

hepatic surgery (blood flow considerations)

A

HIGHLY VASCULAR 1.5 L/m
80% supplied by portal vein
20% hepatic artery

83
Q

liver resection preop work-up

A

CT/MRI for tumor location
12 lead EKG/echo
CXR
CBC/PT/PTT/bldg time, CMP, LFTs

84
Q

optimize your liver patient

A

Vit K, recombinant factor 7 or FFP in emergency

consider plt infusion if < 100k

85
Q

liver patient stomach considerations

A

assume full stomach (ascites, decreased motility)

H2 blocker, reglan, sodium citrate

86
Q

liver resection monitoring

A

a-line
CVP or PA if pulmonary HTN
TEG to guide blood product admin
foley

87
Q

liver resection intraop

A

local/mac (adequate sedation to minimize SNS)

GETA (RSI)

88
Q

liver resection & drug alterations

A

benzo - decreased clearance, prolonged half life
dex - same ^
propofol - one dose is normal response, recovery times longer after infusions

89
Q

liver dx & meperidine

A

neurotoxicity d/t doubling of half life

exaggerated sedative and resp. depression

90
Q

liver dx & sufentanil

A

PK not altered rly

91
Q

liver dx & alfentanil

A

e1/2 doubled

92
Q

nmbd & liver dx

A

increased volume of distribution may require a higher initial dose

93
Q

panc/vec/roc & liver dx

A

prolonged DOA

94
Q

cisatracurium & liver dx

A

wnl

95
Q

sux & liver dx

A

prolonged

96
Q

catecholamines & liver dx

A

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
Q

intraop fluid management liver resection

A

CVP < 5 cm H2O

98
Q

what does the spleen do

A

lymphatic system

  1. filters foreign substances & removes blood
  2. regulates Q to liver; sequestration
  3. very vascular (300 mL/m)
99
Q

splenectomy open/lap

A

indications: trauma, abscess, CA, ITP, hodgkin’s staging

100
Q

bariatric surgery pt BMI

A

> 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
Q

malabsorptive procedures

A

jejunoileal bypass and biliopancreatic diversion

102
Q

restrictive procedures

A

gastroplasty (VBG) - pouch created to communicate w/stomach

adjustable gastric banding (AGB)

103
Q

combined restrictive & malabsorptive

A

roux-en-y gastric bypass (RYGB)
most common
anastomosing proximal gastric pouch to proximal jejunum

104
Q

lap bariatric surgery advantages

A 
less pain
lower morbidity
faster recovery
less 3rd spacing
decreased infection
105
Q

lap bariatric sx disadvantages

A

complete nmb necessary
positioning requirements increase the fall risk
high risk for rt main stem
rhabdo is higher

106
Q

anesthesia considerations for gastric stimulator

A

valsava will dislodge electrodes

ekg interference

107
Q

or table max weight

A

200 kg

108
Q

mortality in 20 day periop period for bariatric sx d/t

A

PE

preop aspirin & warfarin to INR 2.3

109
Q

obesity & fluid balance

A

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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