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Advanced Anesthesia Test#2 > GYN procedures > Flashcards

GYN procedures Flashcards

1
Q

The main supply of blood comes from the ___________ artery. Which is a branch of the _________ __________ artery

A

Uterine artery

Internal iliac artery (main artery in the pelvis)

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2
Q

T or F the uterus wall is very thin

A

FALSE

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3
Q

because the Uterine wall is thick it can result in ________ amount of blood loss.

A

massive

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4
Q

What are the three layers of the uterus going from the outside towards the center

A

Endometrium
Myometrium
Perimetrium

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5
Q

What do you have to be sensitive to when dealing women and GYN procedures

A

Physiological Issues

embarrassment, anxiety, fear, guilt, etc.

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6
Q

Why is the Uterus at risk for a an air embolism or amniotic fluid embolism?

A

Because the Uterus is very vascular and the pt is generally in lithotomy position, steep trendelenburg… resulting in the uterus veins to be higher than the heart.

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7
Q

How much of the cardiac output goes to the uterine blood flow?

A

10%

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8
Q

What is unique about uterine blood flow that makes it more prone to large blood loss.

A

generally it is already maximally dilated resulting in large blood loss.

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9
Q

What viscera and nerves innovates the Uterus?

A

pain to the intaperitoneal pelvic viscera through from nerves plexuses ranging from L4-L5 to spinal nerves T11- T12

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10
Q

What viscera and nerves innovates the Cervix?

A

Pain form the sub peritoneal pelvic viscera (cervix and upper vagina) and goes via pelvic splanchnic nerves to S2- S4

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11
Q

What nerves innovates the vagina

A

the via pudendal nerves to S2,S3,S4

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12
Q

What does perineal surgery refer to?

A

all external genials up to the anal canal.

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13
Q

What does transvaginal mean

A

anything done through the vagina and offers access to the cervix and inner uterus.

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14
Q

What does Intra-abdominal refer to

A

anything done through a the stomach

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15
Q

What does trans-abdomnal refer to?

A

Laperscopic surgery

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16
Q

What is the most common nerve injury?

A

Ulnar nerve injury

Ulnar nerve is part of the brachial plexus

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17
Q

What is the 2nd most common nerve injury

A

brachial plexus

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18
Q

what is the most common lower extremity nerve injury?

A

Common peroneal

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19
Q

Candy cane stirrups generally cause what kind of nerve injury

A

common peroneal

which will lead to foot drop due to pressure on the outer portion of the thigh

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20
Q

Allans stirrups generally cause what kind of nerve injury?

A

Saphenous

due to nerve compression along the medial calf

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21
Q

What major nerve is the saphenous nerve part of? and it is a sensory or motor nerve

A

Femoral nerve

Sensory (why the patient only has a numbness

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22
Q

lack of what action generally leads to an ulnar nerve injury?

A

not positioning the arms

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23
Q

What action generally leads to a brachial plexus nerve injury?

A

not securing the arms to the arm boards so they either fall off the arm boards or the they roll back when placed in trendelenburg.
Also abducting the arms more than 90 degrees will result in an over-streching of the brachial plexus over the humoral head.

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24
Q

What causes damage to the sciatic nerve?

A

over flexing of the hips.

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25
Q

In the Lithotomy position central blood volume ___________ due to the elevation of the LE.

This will result in an ________________ in CVP and PAP.

A

Increase

Increase

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26
Q

Is there a significant change in CO or BP in a health patient in the lithotomy position?

A

Nope (according to Jen)

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27
Q

Cardiac Output will _____________ with trendelenburg position?

FRC and V/Q ratios will ____________ in trendelenburg position?

A

Increase

Decrease

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28
Q

What causes compartment syndrome in Lithotomy position? (Rare complication)

A

-prolonged surgery with the legs elevated results in decreased blood flow which is then further complicated by the drop in BP caused by anesthesia.

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29
Q

How can you prevent compartment syndrome and what type of stirrups are more associated with compartment syndrome?

A

have the patent wear TEDs or SCDs and avoid prolonged surgery

Candy canes :(

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30
Q

what factors make the GYN patient at risk for PONV

A 
trendelenburg position
narcs
female
GYN
stress
electroylte embalance due to NPO
Pain
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31
Q

what is the mechanism of action and indications for Oxytocin (pitocin) ?

A
  • Induces labor
  • decreases uterine hypotonicity
  • reduce hemorrhage postpartum or after abortion
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32
Q

Does of Oxytocin and route of administration

A

20-40 units in a liter of fluid

-side note: hang as a secondary IV… that way if patient become hypptensive. you can give volume quickly

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33
Q

What are the risk of Oxytocin?

A
  • Rapid IV infusion can cause
  • —transient hypotension due to the relaxation of vascular smooth muscle
  • —rapid tachycardia
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34
Q

what is the mechanism of action and indications for Pitressin (vasopressein) ?

A

exogenous prearation fo the hormone vasopressin (ADH) that is secrested by the posterior piutuary gland

```decreases bleeding by vasoconstriction

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35
Q

Does of Pitressin and route of administration

A

DIRECT INJECTION when using for GYN.

-20 Units in 20 ml solution

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36
Q

What are the risk of Pitressin?

A
  • VASOCONSTRICTION of coronary arteries- -vasospasm

- myocardial ischemia

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37
Q

What is the mechanism of action of Methergine (methylergonovine) and what are the indications??

A

-ergot derivative
• Increased uterine tone
• To decrease hemorrhage

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38
Q

What is the Dose and Route of administering Methergine (methylergonovine)?

A

Route of Administration: IM 0.2 mg (ONLY)

SEVERE hypertension if given IV

39
Q

What are the risk in giving Methergine (methylergonovine)?

A

Risks:

  • IV administration results in severe hypertension,
  • seizures
  • CVA
  • retinal detachment.

***Avoid in patients with essential HTN and PVD.

40
Q

What medications are contraindicated for pregnant women and why?

A

Versed - abnormalities and women don’t remember the birth of their children

Nitrous- abnormalities

41
Q

Is GA contraindicated for pregnancy?

A

No, but it should be avoided. especially in the first trimester.

42
Q

Why is a cervical cerclage done?

A

to prevent second trimester pregnancy loss due to
incompetent cervical os
• done between 14 and 21 weeks gestation

43
Q

What are some anesthesia considerations for a cervical cerclage?

A

Fetal Heart rate monitor
Subaraccnoid block - level T8-10

Normally done in Office

44
Q

What effect does cryo work by?

A

Joule-thompson effect

45
Q

What is the normal plan of anesthesia for transvaginal procedures?

A

MAC and maybe a block if pt cant handle doing procdure in office

46
Q

What is the most painful part of an D&C?

A

the dilation.

47
Q

Why would a patient become brady during a D&C

A

the cervix is highly enervated by the nervous system resulting in bradycardia and possible a laringospasm

(i dont know why…weird)

48
Q

what are some anesthesia considerations for a D & C?

What plan of anesthesia is an option?

A
  • you want to know when they are stretching
  • can be done local c mac or GA
  • subarachnoid, but at an increased risk for post-puncture headache
49
Q

What is the difference between a D & C and a D & E?

A

Dilatation and Curettage (D&C)
-to diagnose and treat abnormal uterine
bleeding or to complete incomplete or missed abortions

Dilatation and Evacuation (D&E)-due to fetal demise
• Done 2nd + 3rd trimester
• Requires wider cervical dilation
• Need forceps to evacuate more advanced pregnancies (13-16 wks. vacuum alone adequate)

50
Q

What is a risk that occurs during a D & C?

A

Risks:

  • uterine perforation/hemorrhage
  • bracycardia
  • laringospasm
51
Q

What are the risk associated with a D & E?

A

Risks:

  • uterine abruption=sudden acute abdominal pain
  • bleeding - normally give oxytocin after to contract the uterus.
  • Amniotic fluid embolism/ DIC
  • Infection
  • bradycardia
  • layringospasm
52
Q

What surgery is known cause the “female TURP syndrome”

A

Hysteroscopy

53
Q

What things do we need to monitor to avoid “female TURP syndrome”

A
  • intake and output (preventing fluid overload)
  • Infusion Pressure
  • neuro status
  • blood sugar (Glyince, Mannitol, & Sorbitol)
54
Q

Osmolality, Advantages, and Disadvantages of Glycine

A

O= 200

A= Good optical qualities, Less likelihood of TURP syndrome

D= ***Hyperammonemia
**Transient postop visual syndrome
Hyponatremia / Hypotonic fluid overload

55
Q

Osmolality, Advantages, and Disadvantages of Sorbitol?

A 
O= 178
A=Good optical  qualities
D=Hyponatremia
Hypotonic Fluid overload
Hyperglycemia
56
Q

Osmolality, Advantages, and Disadvantages of Normal Saline?

A

O= 308
A=Minimal effects with absorbtion
D=Current Dispersion

57
Q

Osmolality, Advantages, and Disadvantages of Mannitol?

A 
O= 285
A= minimal effects with absorbtion
D= Hyponatremia
***Hyperglycemia***
Isotonic fluid overload
58
Q

Normal patient serum osmolarity is

A

280 mOsm/L

59
Q

For every liter of hypotonic fluid absorbed from the interstitial space,_______ mEq of sodium moves with it into the intravascular space= dilutional hyponatremia

A

ONLY 10 :(

Big risk for dilutional hyponatremia

60
Q

Are pre or post menopausal women at a higher risk for hysteroscopy syndrome-

A

PRE

progesterone derivative inhibit the Na+/K+ pump

61
Q

what medication can pre-menopausal women be on to decrease their chance of TURP syndrome? and what is its mechanism of action?

A

GnRH (gonadotropin-releasing hormone)

creates a post-menopasusal state in the body

62
Q

Development of Fluid overload with hysteroscopy is influenced by:

and what facts can we control to help decrease the possibility of developing fluid overload?

A
  1. Type of irrigation infusion
  2. **Infusion pressure*
  3. Vascularity of the uterus
  4. **duration of surgery*
  5. Surgical technique
63
Q

Risks of Hysteroscopy:

A
  1. Hysteroscopy Syndrome
  2. Hemorrhage
  3. Uterine perforation
  4. Injury to bowel/bladder
  5. Positioning Injuries
  6. VAE - only if the cervix is above the heart
64
Q

How do you monitor the fluid deficit in a hysteroscopy patient?

A

(the volume of fluid infused into the uterine cavity) minus

the volume which passes out into the collection system

65
Q

What should you do if the fluid deficit is 500ml in a hysterocopy?

A

Check a Na+

66
Q

What should you do if the fluid deficit is 1000ml in a hysterocopy?

A

Administer furosemide 20mg

67
Q

What should you do if the fluid deficit is greater than 1-2 Liters in a hysterocopy?

A

STOP the surgery

68
Q

When are you most likely to see the s/s of TURP or dilutional hyponatremia?

A

PACU

69
Q

What are the Neurological and Cardiac Manifestations of a Hyponatremia level of 120?

A

Neruo:
Dizziness
Confusion
Restlessness

Cardiac:
Hypotension
Possible widening of QRS complex
Decreased myocardial contractility

70
Q

What are the Neurological and Cardiac Manifestations of a Hyponatremia level of 115?

A

Neuro:
Retching
Nausea
Somnolence

Cardiac:
Widened QRS
Elevated ST segment
Ventricular ectopy

71
Q

What are the Neurological and Cardiac Manifestations of a Hyponatremia level of 110?

A 
Neuro:
Seizures
Loss of consciousness
Respiratory Arrest
Coma

Cardiac:
Ventricular tachycardia
Ventricular fibrillation
Cardiac Arrest

72
Q

What are some Anesthesia Considerations for total vaginal hysterectomy?

A
  • supine with arms abducted
  • blood loss
  • bowel prep (*FLUID REPLACEMENT!)
  • GA/regional T4-T6 +/- narcotic
  • vasovagal with cervical manipulation
73
Q

What level is needed for a hysterectomy?

A

T4-T6

74
Q

what are somethings to consider with condylomatous warts (HPV)?

A

surgery usually done with a CO2 laser

-everyone (including pt) needs goggles and N95 mask due to the aerolysation of particles (GROSS)

75
Q

Do people generally lean towards a MAC or GA for GYN procedures?

A

GA- consider the venerability of the pt.
MAC can be done but generally deep
SB- if younger than they are at an increased risk for a post-puncture HA

76
Q

what is removed in a partial/supra-cervical/sub-total hysterectomy?

A

only the uterus

77
Q

What is removed in a total hysterectomy?

A

uterus and cervix

78
Q

What is removed in a radical hysterectomy

A

uterus, cervix, olveries, tubes, and the tissue to the pelvic side walls.

79
Q

What should to laperscopic insufflation pressure be?

A

10-15

80
Q

what are the cardiac effects of insufflation?

A

CO variability
decreased pre-load
increased afterload
possible hypotension

81
Q

What are the pulmonary effects of insufflation?

A

increased PAP
increased Co2 absorption
decreased FRC
decreased lung compliance

82
Q

Anesthesia Considerations for total abdominal hysterectomy

A
  • laparotomy in supine position with arms abducted
  • bowel prep
  • GA/regional +/- narcotic
  • case may be aborted if widely metastatic
  • warming measures
83
Q

Anti-neoplastics

What is the risk if a patient is on Adriamycin?
And what lab test should you order?

A

Cardomyopathy and CHF

-request an ECHO

84
Q

Anti-neoplastics

What is the risk if a patient is on Bleomycin?
And what lab test should you order?

A

pulmonary fibrosis

-request spirometry or PFT

85
Q

Anti-neoplastics

What is the risk if a patient is on Platinol (cisplatin)?

And what lab test should you order?

A

Renal Tubular disfunction

- request creatinine clearance test

86
Q

What are the three classification of myomectomies?

A
  • Submucosal (endometrial)= inner most layer
  • Intramural (myometrial)= middle, thick muscular layer
  • Subserosal (perimetrial)= outer layer
87
Q

What is a Salpingotomy

A

operative opening made in the oviduct that is used to remove an unruptured tubal pregnancy.

-can be laparoscopic

88
Q

What is a Salpingectomy

A

operative removal of an oviduct when a tubal pregnancy has ruptured.
massive hemorrhage

89
Q

What are some anesthesia considerations for a Salpingectomy?

A
  • secure the airway
  • rapid fluid resuscitation
  • ensure T/C and prepare for massive transfusion (ask for O- blood, no time to wait)
90
Q

When is a sterilization done on a post-partum women?

And what are some anesthesia considerations?

A

Post-partum tubal ligation-performed POD 1 or 2

Dont want to do GA on a pregnant ladies airway! Do a regional when appropriate VERY HIGH RISK FOR ASPIRATION*

91
Q

What is the number one cause for maternal death during the first trimester?

A

Ruptured ectopic pregnangcy

92
Q

What regional level is needed for a sterilization procedure?

A

T6

93
Q

What precautions can you take to decreased PONV?

A 
No Nitrous
seratonin blocker
decadron
dopamine blockers
anticholenergic
avoid hypotension
decreased Narcs

Advanced Anesthesia Test#2 (4 decks)

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