GYN procedures Flashcards
The main supply of blood comes from the ___________ artery. Which is a branch of the _________ __________ artery
Uterine artery
Internal iliac artery (main artery in the pelvis)
T or F the uterus wall is very thin
FALSE
because the Uterine wall is thick it can result in ________ amount of blood loss.
massive
What are the three layers of the uterus going from the outside towards the center
Endometrium
Myometrium
Perimetrium
What do you have to be sensitive to when dealing women and GYN procedures
Physiological Issues
embarrassment, anxiety, fear, guilt, etc.
Why is the Uterus at risk for a an air embolism or amniotic fluid embolism?
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.
How much of the cardiac output goes to the uterine blood flow?
10%
What is unique about uterine blood flow that makes it more prone to large blood loss.
generally it is already maximally dilated resulting in large blood loss.
What viscera and nerves innovates the Uterus?
pain to the intaperitoneal pelvic viscera through from nerves plexuses ranging from L4-L5 to spinal nerves T11- T12
What viscera and nerves innovates the Cervix?
Pain form the sub peritoneal pelvic viscera (cervix and upper vagina) and goes via pelvic splanchnic nerves to S2- S4
What nerves innovates the vagina
the via pudendal nerves to S2,S3,S4
What does perineal surgery refer to?
all external genials up to the anal canal.
What does transvaginal mean
anything done through the vagina and offers access to the cervix and inner uterus.
What does Intra-abdominal refer to
anything done through a the stomach
What does trans-abdomnal refer to?
Laperscopic surgery
What is the most common nerve injury?
Ulnar nerve injury
Ulnar nerve is part of the brachial plexus
What is the 2nd most common nerve injury
brachial plexus
what is the most common lower extremity nerve injury?
Common peroneal
Candy cane stirrups generally cause what kind of nerve injury
common peroneal
which will lead to foot drop due to pressure on the outer portion of the thigh
Allans stirrups generally cause what kind of nerve injury?
Saphenous
due to nerve compression along the medial calf
What major nerve is the saphenous nerve part of? and it is a sensory or motor nerve
Femoral nerve
Sensory (why the patient only has a numbness
lack of what action generally leads to an ulnar nerve injury?
not positioning the arms
What action generally leads to a brachial plexus nerve injury?
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.
What causes damage to the sciatic nerve?
over flexing of the hips.
In the Lithotomy position central blood volume ___________ due to the elevation of the LE.
This will result in an ________________ in CVP and PAP.
Increase
Increase
Is there a significant change in CO or BP in a health patient in the lithotomy position?
Nope (according to Jen)
Cardiac Output will _____________ with trendelenburg position?
FRC and V/Q ratios will ____________ in trendelenburg position?
Increase
Decrease
What causes compartment syndrome in Lithotomy position? (Rare complication)
-prolonged surgery with the legs elevated results in decreased blood flow which is then further complicated by the drop in BP caused by anesthesia.
How can you prevent compartment syndrome and what type of stirrups are more associated with compartment syndrome?
have the patent wear TEDs or SCDs and avoid prolonged surgery
Candy canes :(
what factors make the GYN patient at risk for PONV
trendelenburg position narcs female GYN stress electroylte embalance due to NPO Pain
what is the mechanism of action and indications for Oxytocin (pitocin) ?
- Induces labor
- decreases uterine hypotonicity
- reduce hemorrhage postpartum or after abortion
Does of Oxytocin and route of administration
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
What are the risk of Oxytocin?
- Rapid IV infusion can cause
- —transient hypotension due to the relaxation of vascular smooth muscle
- —rapid tachycardia
what is the mechanism of action and indications for Pitressin (vasopressein) ?
exogenous prearation fo the hormone vasopressin (ADH) that is secrested by the posterior piutuary gland
```decreases bleeding by vasoconstriction
Does of Pitressin and route of administration
DIRECT INJECTION when using for GYN.
-20 Units in 20 ml solution
What are the risk of Pitressin?
- VASOCONSTRICTION of coronary arteries- -vasospasm
- myocardial ischemia
What is the mechanism of action of Methergine (methylergonovine) and what are the indications??
-ergot derivative
• Increased uterine tone
• To decrease hemorrhage
What is the Dose and Route of administering Methergine (methylergonovine)?
Route of Administration: IM 0.2 mg (ONLY)
SEVERE hypertension if given IV
What are the risk in giving Methergine (methylergonovine)?
Risks:
- IV administration results in severe hypertension,
- seizures
- CVA
- retinal detachment.
***Avoid in patients with essential HTN and PVD.
What medications are contraindicated for pregnant women and why?
Versed - abnormalities and women don’t remember the birth of their children
Nitrous- abnormalities
Is GA contraindicated for pregnancy?
No, but it should be avoided. especially in the first trimester.
Why is a cervical cerclage done?
to prevent second trimester pregnancy loss due to
incompetent cervical os
• done between 14 and 21 weeks gestation
What are some anesthesia considerations for a cervical cerclage?
Fetal Heart rate monitor
Subaraccnoid block - level T8-10
Normally done in Office
What effect does cryo work by?
Joule-thompson effect
What is the normal plan of anesthesia for transvaginal procedures?
MAC and maybe a block if pt cant handle doing procdure in office
What is the most painful part of an D&C?
the dilation.
Why would a patient become brady during a D&C
the cervix is highly enervated by the nervous system resulting in bradycardia and possible a laringospasm
(i dont know why…weird)
what are some anesthesia considerations for a D & C?
What plan of anesthesia is an option?
- 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
What is the difference between a D & C and a D & E?
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)
What is a risk that occurs during a D & C?
Risks:
- uterine perforation/hemorrhage
- bracycardia
- laringospasm
What are the risk associated with a D & E?
Risks:
- uterine abruption=sudden acute abdominal pain
- bleeding - normally give oxytocin after to contract the uterus.
- Amniotic fluid embolism/ DIC
- Infection
- bradycardia
- layringospasm
What surgery is known cause the “female TURP syndrome”
Hysteroscopy
What things do we need to monitor to avoid “female TURP syndrome”
- intake and output (preventing fluid overload)
- Infusion Pressure
- neuro status
- blood sugar (Glyince, Mannitol, & Sorbitol)
Osmolality, Advantages, and Disadvantages of Glycine
O= 200
A= Good optical qualities, Less likelihood of TURP syndrome
D= ***Hyperammonemia
**Transient postop visual syndrome
Hyponatremia / Hypotonic fluid overload
Osmolality, Advantages, and Disadvantages of Sorbitol?
O= 178 A=Good optical qualities D=Hyponatremia Hypotonic Fluid overload Hyperglycemia
Osmolality, Advantages, and Disadvantages of Normal Saline?
O= 308
A=Minimal effects with absorbtion
D=Current Dispersion
Osmolality, Advantages, and Disadvantages of Mannitol?
O= 285 A= minimal effects with absorbtion D= Hyponatremia ***Hyperglycemia*** Isotonic fluid overload
Normal patient serum osmolarity is
280 mOsm/L
For every liter of hypotonic fluid absorbed from the interstitial space,_______ mEq of sodium moves with it into the intravascular space= dilutional hyponatremia
ONLY 10 :(
Big risk for dilutional hyponatremia
Are pre or post menopausal women at a higher risk for hysteroscopy syndrome-
PRE
progesterone derivative inhibit the Na+/K+ pump
what medication can pre-menopausal women be on to decrease their chance of TURP syndrome? and what is its mechanism of action?
GnRH (gonadotropin-releasing hormone)
creates a post-menopasusal state in the body
Development of Fluid overload with hysteroscopy is influenced by:
and what facts can we control to help decrease the possibility of developing fluid overload?
- Type of irrigation infusion
- **Infusion pressure*
- Vascularity of the uterus
- **duration of surgery*
- Surgical technique
Risks of Hysteroscopy:
- Hysteroscopy Syndrome
- Hemorrhage
- Uterine perforation
- Injury to bowel/bladder
- Positioning Injuries
- VAE - only if the cervix is above the heart
How do you monitor the fluid deficit in a hysteroscopy patient?
(the volume of fluid infused into the uterine cavity) minus
the volume which passes out into the collection system
What should you do if the fluid deficit is 500ml in a hysterocopy?
Check a Na+
What should you do if the fluid deficit is 1000ml in a hysterocopy?
Administer furosemide 20mg
What should you do if the fluid deficit is greater than 1-2 Liters in a hysterocopy?
STOP the surgery
When are you most likely to see the s/s of TURP or dilutional hyponatremia?
PACU
What are the Neurological and Cardiac Manifestations of a Hyponatremia level of 120?
Neruo:
Dizziness
Confusion
Restlessness
Cardiac:
Hypotension
Possible widening of QRS complex
Decreased myocardial contractility
What are the Neurological and Cardiac Manifestations of a Hyponatremia level of 115?
Neuro:
Retching
Nausea
Somnolence
Cardiac:
Widened QRS
Elevated ST segment
Ventricular ectopy
What are the Neurological and Cardiac Manifestations of a Hyponatremia level of 110?
Neuro: Seizures Loss of consciousness Respiratory Arrest Coma
Cardiac:
Ventricular tachycardia
Ventricular fibrillation
Cardiac Arrest
What are some Anesthesia Considerations for total vaginal hysterectomy?
- supine with arms abducted
- blood loss
- bowel prep (*FLUID REPLACEMENT!)
- GA/regional T4-T6 +/- narcotic
- vasovagal with cervical manipulation
What level is needed for a hysterectomy?
T4-T6
what are somethings to consider with condylomatous warts (HPV)?
surgery usually done with a CO2 laser
-everyone (including pt) needs goggles and N95 mask due to the aerolysation of particles (GROSS)
Do people generally lean towards a MAC or GA for GYN procedures?
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
what is removed in a partial/supra-cervical/sub-total hysterectomy?
only the uterus
What is removed in a total hysterectomy?
uterus and cervix
What is removed in a radical hysterectomy
uterus, cervix, olveries, tubes, and the tissue to the pelvic side walls.
What should to laperscopic insufflation pressure be?
10-15
what are the cardiac effects of insufflation?
CO variability
decreased pre-load
increased afterload
possible hypotension
What are the pulmonary effects of insufflation?
increased PAP
increased Co2 absorption
decreased FRC
decreased lung compliance
Anesthesia Considerations for total abdominal hysterectomy
- laparotomy in supine position with arms abducted
- bowel prep
- GA/regional +/- narcotic
- case may be aborted if widely metastatic
- warming measures
Anti-neoplastics
What is the risk if a patient is on Adriamycin?
And what lab test should you order?
Cardomyopathy and CHF
-request an ECHO
Anti-neoplastics
What is the risk if a patient is on Bleomycin?
And what lab test should you order?
pulmonary fibrosis
-request spirometry or PFT
Anti-neoplastics
What is the risk if a patient is on Platinol (cisplatin)?
And what lab test should you order?
Renal Tubular disfunction
- request creatinine clearance test
What are the three classification of myomectomies?
- Submucosal (endometrial)= inner most layer
- Intramural (myometrial)= middle, thick muscular layer
- Subserosal (perimetrial)= outer layer
What is a Salpingotomy
operative opening made in the oviduct that is used to remove an unruptured tubal pregnancy.
-can be laparoscopic
What is a Salpingectomy
operative removal of an oviduct when a tubal pregnancy has ruptured.
massive hemorrhage
What are some anesthesia considerations for a Salpingectomy?
- secure the airway
- rapid fluid resuscitation
- ensure T/C and prepare for massive transfusion (ask for O- blood, no time to wait)
When is a sterilization done on a post-partum women?
And what are some anesthesia considerations?
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*
What is the number one cause for maternal death during the first trimester?
Ruptured ectopic pregnangcy
What regional level is needed for a sterilization procedure?
T6
What precautions can you take to decreased PONV?
No Nitrous seratonin blocker decadron dopamine blockers anticholenergic avoid hypotension decreased Narcs
