GU/Ortho Flashcards by Brooke Harris

what anesthetic techniques are used for common peds GU procedures?

(circumcision, hypospadius, orchiopexy, inguinal hernia)

GA +/- regional blocks or caudals

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which 3 procedures are associated with a high risk of laryngospasm?

foreskin, hernia, and testes retraction

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what is a hypospadius/chordee?

urethra opens on the underside of the penis

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what is MAGPI?

what is it for?

meatal advancement and glanuloplasty
hypospadius/chordee

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what is an orchiopexy?

undescended testes repair to pull them down into the scrotum
may require fixation

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airway considerations for hypospadius vs orchiopexy?

hypospadius can use LMA

orchiopexy must have ETT: probable laryngospasm, need deep anesthesia & NMB

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what block is sometimes used for circumcision?

penile block

*done by surgeon ptl

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what is ureteral reimplantation for?

considerations?

reflux at the ureter/bladder junction
procedure lasts several hours, heavy retractor use

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what anesthetic techniques work well for a ureteral reimplantation?

GA + caudal

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what is a pyeloplasty for?

GU reflux at the ureter/kidney pelvis junction

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positioning for a pyeloplasty

usually done lateral with kidney flexion, sometimes prone

(Lisa says 50/50)

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anesthetic techniques used for pyeloplasties

regional gaining popularity

*caudals do NOT work well

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which GU procedure is only done unilaterally - ureteral reimplantation or pyeloplasty

why?

pyeloplasy is only unilateral - to avoid kidney failure with bilateral swelling

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what is a nephrectomy used for?

non-functioning, dysplastic kidney, stones, cancer
or chronic disease causing anemia, HTN

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positioning for nephrectomy?

consideration if doing partial nephrectomy vs total?

lateral with kidney flexion or prone
partial nephrectomy has an increased risk of high blood loss

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what is bladder and cloacal extrophy?

failure of abdominal wall to close over anterior bladder wall

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what other anomalies are often seen with bladder and cloacal extrophy?

CV defects
cloacal exstrophy - omphaloceles, spinal defects, imperforate anus

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surgical plan for bladder and cloacal exstrophy?

intra-op complication often seen?

high intraoperative third space loss
staged repair (closure of bladder, urethra, abdominal wall)
requires MANY procedures, sometimes over years

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classifications of scoliosis

idiopathic (unknown etiology)
congenital (spina bifida)
neuromuscular (Duchenne MD)
mesenchymal (arthrogryposis)

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how is pulmonary compromise determined in scoliosis?

when do we see respiratory changes?

pulmonary compromise correlates with degree of curve
vital capacity begins to decrease at 60°
becomes severe at 100°

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what is the difference in neuromuscular scoliosis patients vs others?

(patho, major risk)

deteriorating muscle function + mechanical distortion
prolonged PTT and decreased factor VII activity
higher blood loss - 5 x higher risk than idiopathics
TXA routine for NMs in many centers

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what two factors indicate a high risk scoliosis repair?

non-ambulatory + 60º curve

in a little toddler bby, what would be a much safer/option if possible to do instead of a big open scoliosis repair?

serial casting

three huge considerations for posterior spinal fusions

long

bloody

high risk

pre-op for spinal fusions \*kinda long pls break up

* thorough history * CBC, electrolytes, coags (other diagnostics if indicated based on history) * PRBCs ***_must_*** be available – confirm with blood bank * detailed informed consent * describe post-op scenario (ICU, edema, pain mgt, etc.)

large ass list of things that should be done before flipping what is the very last thing done before flipping?

last thing: disconnect EVERYTHING * 2 large IVs (at least 1 warmed) * blood set-up * arterial line * foley * esophageal temp probe * bite block * eyes lubed/taped securely * evoked potential electrodes in place

positioning for spinal fusion what can be used to minimize cardiac (??) effects?

prone Jackson table may minimize cardiac effects

major positioning risk for spinal fusions

post-op vision loss usually due to ischemic optic neuropathy and _unrelated to globe pressure_ \*document eye checks

T/F: post-op vision loss after spinal fusion is usually due to increased globe pressure

false usually due to **ischemic optic neuropathy** and _unrelated_ to globe pressure

biggest risk factors for complications from positioning for spinal fusions

\>6 hours high blood loss [I think these are the risk factors for vision loss specifically]

a 2º C drop in core temp has what effects?

3 times increased risk of wound infection

what monitors are used for spinal fusion?

* standards * art line * SSEP/MEP * foley

do we use NMBs in spinal fusion cases? why or why no?

no - need to use SSEP

considerations/complications for spinal fusions (not related to their eye balls)

* huge 3rd space loss * high blood loss * long procedures (5-10 hrs)

post-op considerations for spinal fusions

* ICU post-op * consider PCA for post-op pain mgt

\*dumb as heck instruments used for spinal fusions

* pedicle screws * vertical expandable prosthetic titanium rib rod (VEPTR) * Harrington rods

MAP goal for controlled hypotension? considerations and meds often used

* MAP goal: 50-65 mmHg * must have AL * drugs: opioids, precedex, clonidine, calcium channel blockers

what can be used for hemodilution?

either colloid or crystalloid

what is the most common antifibrinolytic used for spinal fusion? what type of patients benefit from this the most?

TXA neuromuscular scoliosis pts show the most significant results

if the patient has dilutional thrombocytopenia, what do we give?

platelets

if the patient is “oozy” what do we give?

FFP and draw coags

if the patient has refractory bleeding what do we give?

novo 7

what are ways to manage blood loss during spinal fusions? (8)

* controlled hypotensin * hemodilution * autologous and/or directed donation * antifibrinolytics * cell saver * plts * FFP * novo 7

which is more vulnerable to ischemia during hardware insertion - motor pathways or sensory pathways? why?

motor - perfused by single anterior spinal artery

what are the three ways to check for intact motor pathways during spinal fusion? which one isnt used much anymore?

* SSEP (used with MEP) – doesn't this only tests sensory, not motor? * MEP (now being used alone) * wake-up test - not used as much

anesthetic effects on SSEP?

* decrease amplitude * increase latency

what is key to successful evoked potential monitoring?

communication

what drugs should be avoided when monitoring evoked potentials?

* nitrous - significant EP depression * volatiles \> 0.5 MAC * muscle relaxants (if using MEPs; little effect on SSEPs)

what drugs preserve EP and are ok to use during SSEP monitoring? (6)

* propofol * opioids * ketamine * etomidate * dexmedetomidine * clonidine

common anesthetic technique when monitoring SSEP

propofol infusion + opioid infusion (remifentanil or sufentanil)

why is wake-up testing sometimes done? what is an absolute must?

* ensure sensory and motor pathways remain intact throughout procedure * must have good pre-op education

how do we do wake-up testing?

* anesthetic lightened after hardware insertion * patient told to move feet * after bilateral foot movement confirmed, patient “re-induced

problems with wake-up testing

* HTN * tachycardia * blood loss * risk of recall during period of light anesthesia