GU/Ortho Flashcards
what anesthetic techniques are used for common peds GU procedures?
(circumcision, hypospadius, orchiopexy, inguinal hernia)
GA +/- regional blocks or caudals
which 3 procedures are associated with a high risk of laryngospasm?
foreskin, hernia, and testes retraction
what is a hypospadius/chordee?
urethra opens on the underside of the penis
what is MAGPI?
what is it for?
- meatal advancement and glanuloplasty
- hypospadius/chordee
what is an orchiopexy?
- undescended testes repair to pull them down into the scrotum
- may require fixation
airway considerations for hypospadius vs orchiopexy?
hypospadius can use LMA
orchiopexy must have ETT: probable laryngospasm, need deep anesthesia & NMB
what block is sometimes used for circumcision?
penile block
*done by surgeon ptl
what is ureteral reimplantation for?
considerations?
- reflux at the ureter/bladder junction
- procedure lasts several hours, heavy retractor use
what anesthetic techniques work well for a ureteral reimplantation?
GA + caudal
what is a pyeloplasty for?
GU reflux at the ureter/kidney pelvis junction
positioning for a pyeloplasty
usually done lateral with kidney flexion, sometimes prone
(Lisa says 50/50)
anesthetic techniques used for pyeloplasties
regional gaining popularity
*caudals do NOT work well
which GU procedure is only done unilaterally - ureteral reimplantation or pyeloplasty
why?
pyeloplasy is only unilateral - to avoid kidney failure with bilateral swelling
what is a nephrectomy used for?
- non-functioning, dysplastic kidney, stones, cancer
- or chronic disease causing anemia, HTN
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
what is bladder and cloacal extrophy?
failure of abdominal wall to close over anterior bladder wall
what other anomalies are often seen with bladder and cloacal extrophy?
- CV defects
- cloacal exstrophy - omphaloceles, spinal defects, imperforate anus
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
classifications of scoliosis
- idiopathic (unknown etiology)
- congenital (spina bifida)
- neuromuscular (Duchenne MD)
- mesenchymal (arthrogryposis)
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°
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
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
