Lap & Gyn Flashcards
Laparoscopic surgery, once a groundbreaking innovation, is now the standard of care for what procedures? (4)
- cholecystectomy
- appendectomy
- bariatric surgery
- complex oncological resections
what are the benefits to laparoscopic surgery? (4)
- minimally invasive
- reduces postoperative pain
- accelerates recovery
- decreases morbidity
what specific physiological stresses can occur with laparoscopic surgery (2)
- creation of pneumoperitoneum
- extreme patient positioning
Robotic-assisted surgery is usually of what nature? (4)
- urology
- gynecology
- colorectal surgery
- thoracic
benefits of the Da Vinci (3)
- improved precision
- dexterity
- visualization
Robotic systems complicates anesthetic management due to
(3)
- the limited access to the patient once the robotic arms are docked
- the prolonged duration of surgeries
- physiological strain induced by steep Trendelenburg positioning, especially during pelvic surgeries
Pneumoperitoneum introduces significant ____________.
cardiovascular changes
The insufflation of carbon dioxide (CO2) into the peritoneal cavity raises intra-abdominal pressure (IAP), typically to ____________________
12-15 mmHg.
what does an increase in intra-abdominal pressure cause?
Increase in IAP compresses the inferior vena cava (IVC): reducing venous return and, consequently, decreasing preload
In patients with compromised cardiac function, compensatory mechanisms may be insufficient
in a patient with severe aortic stenosis, the patient relies heavily on
a fixed preload to maintain adequate stroke volume
Hemodynamic instability can occur rapidly if
preload is not carefully maintained
how can preload be maintained? (3)
- appropriate fluid management
- inotropic support
- reducing the pneumoperitoneum pressure temporarily.
CO2 insufflation triggers the release of ____________ leading to ____________
catecholamines; vasoconstriction and increased afterload.
In patients with left ventricular hypertrophy (LVH) or diastolic dysfunction, an increase in afterload ….
exacerbates the workload on an already stiff left ventricle
Patients may struggle to maintain stroke volume, leading to… (3)
- diastolic heart failure
- pulmonary edema
- increased myocardial oxygen consumption.
Transesophageal echocardiography (TEE) can be a useful tool to monitor:
- ventricular filling pressures
- wall motion abnormalities
- the adequacy of preload and afterload management in real time.
CO2 absorption during pneumoperitoneum can lead to …
hypercarbia, which directly affects the cardiovascular system by increasing sympathetic nervous system activity.
what does hypercarbia do to the cardiovascular system?
Dilates most vascular beds, but paradoxically, increases heart rate and blood pressure due to SNS stimulation
In patients with coronary artery disease, the combination of increased heart rate, increased myocardial oxygen demand, and reduced coronary perfusion (due to higher SVR) can precipitate ____________ during pneumoperitoneum
myocardial ischemia
What respiratory changes may develop when PaCO2 rises above 60 mmHg
mixed respiratory and metabolic acidosis develop, further complicating the hemodynamic picture.
Patients with pre-existing lung disease, such as chronic obstructive pulmonary disease (COPD) or restrictive lung disease, are particularly vulnerable to elevated PaCo2 because ____________
their ability to clear CO2 is already compromised.
Patients with pre-existing lung disease may require what ventilatory management if they have an elevated PaCO2?
- increased respiratory rates
- higher tidal volumes
- conversion to pressure-controlled ventilation to prevent barotrauma
Consider a patient with a history of a recent myocardial infarction, now presenting for a laparoscopic colon resection.
What might you see?
- CO2 insufflation begins and the patients end-tidal CO2 rises to 50 mmHg
- HR increases from 75 to 100 bpm
- EKG begins to show subtle ST-segment depression
(This is a classic scenario where hypercarbia, combined with increased afterload, is exacerbating myocardial ischemia.)
Immediate interventions (3) for myocardial ischemia caused by hypercarbia
- increasing minute ventilation to reduce PaCO2
- administering beta-blockers to slow heart rate and reduce myocardial oxygen demand,
- possibly reducing pneumoperitoneum pressure to alleviate the hemodynamic stress.
what does Trendelenburg position do to the cardiovascular system?
immediate management for acute pulmonary edema (3)
- placing the patient in reverse Trendelenburg to decrease venous return,
- administering diuretics to reduce preload
- nitroglycerin to reduce afterload.
manifestations of acute pulmonary edema (2)
- frothy secretions in the endotracheal tube
- a sudden drop in oxygen saturation.
The creation of a pneumoperitoneum leads to significant changes in respiratory mechanics due to ____________
the elevation of the diaphragm.
what does elevation of the diaphragm do to FRC
This reduces functional residual capacity (FRC), particularly affecting the dependent lung regions.
As the diaphragm is pushed upwards, lung compliance decreases, which … (2)
- increases airway pressures
- reduces tidal volumes.
a decreased lung compliance from upward push of diaphragm is pronounced in what patient populations?
- obese patients, where baseline FRC is already reduced,
- patients with restrictive lung diseases, where lung compliance is further impaired.
T/F:
Everyone will have some sort of atelactasis after insufflation.
True
instruct them to take deep breaths after surgery
Lap Surgery
Healthy vs Compromised patients
usually tolerates changes well (unless they’re dry and will become hypotensive), if ventilatory settings maintain adequate oxygenation and ventilation
lap Sx changes can precipitate respiratory failure if severe COPD or interstital lung disease
Recommended setting for single lung ventilation
- Vt 390-490
- PEEP 8-10
- RR 16-17 (faster to lower etCO2)
- dont exTT if CO2 abnormally high
- obtain gas if needed
Scenario:
* laparoscopic sleeve gastrectomy
* BMI of 40
* end-tidal CO2 increases despite an increase in minute ventilation
* peak airway pressures rise above 35 cmH2O, indicating poor lung compliance
- switch to pressure-control, applying PEEP to prevent alveolar collapse
- ensuring tidal volumes are adjusted to prevent barotrauma (6-8 mL/kg of ideal body weight
Volume-controlled ventilation (VCV) ensures consistent tidal volumes, which is important for….
maintaining adequate alveolar ventilation in the face of reduced lung compliance.
Cons of VCV ventilation for insufflation
often leads to high peak airway pressures
esp Trendelenburg or obese
You have high peak pressures on VCV. Why switch to PCV?
limits peak airway pressures while allowing tidal volumes to fluctuate based on lung compliance
T/F:
Volume control ventilation will allow tidal volumes to fluctuate based on lung compliance.
False
PCV
Lap Surgery
When would you want to obtain a gas prior to exTT?
unable to correct introp etCO2 of 50-60 without aggressive Vt and PEEP
When to use permissive hypercapnia as it may be necessary to avoid the risk of barotrauma
COPD and other significant respiratory pathology
significant respiratory pathology (ex: severe COPD) have high baseline ___ levels due to impaired ___ clearance
high baseline PaCO2
impaired CO2 clearance
T/F:
The CRNA must normalize the etCO2 in a patient with COPD.
False
normalizing PaCO2 through aggressive ventilation can lead to dangerously high airway pressures and ventilator-induced lung injury (VILI)
You’ve decided to employ permissive hypercapnia in your severe emphysema patient. What does this require?
allowing PaCO2 to rise to 55-60
provided that oxygenation is maintained and acidosis is not severe
Which patients are at risk for postop resp complications from lap surgery? What complications may occur?
lung disease, obese, OSA
atelectasis, hypoxemia, and hypercarbia
To minimize these risks, CPAP or BiPAP immediately postop can be highly effective.
preventing atelectasis and improving postoperative lung function
- Early mobilization
- aggressive pulmonary toilet
- incentive spirometry
- CPAP, BiPAP
Scenario
60 Y/o OSA undergoing laparoscopic hernia repair. Postop, develops significant hypoxemia and hypercapnia, 85% on room air and a PaCO2 of 60 mmHg
- postoperative CPAP to prevent airway collapse and improve oxygenation
- close monitoring in a postop care unit with frequent ABG may be necessary to guide further management
Intraoperative management during laparoscopic and robotic surgery involves a delicate balance of
fluid therapy,
ventilatory support,
monitoring for complications
effects of pneumoperitoneum and positioning are often transient, but their effects can be profound, particularly in…
patients with significant comorbidities
T/F:
One of the key challenges during laparoscopic surgery is managing fluid therapy in the context of the hemodynamic changes induced by pneumoperitoneum.
True
pneumoperitoneum
HD effects
- increased intra-abdominal pressure reduces venous return = ↓ preload & CO
- increases SVR, which raises afterload
⬇️
significant hypotension
esp if impaired cardiac function
Goal-directed fluid therapy (GDFT)
- Effective strategy for managing fluid administration during these procedures.
- dynamic parameters such as stroke volume & pulse pressure variation assess fluid response
Ex:
in laparoscopic colorectal surgery, continuous SVV monitoring might indicate hypovolemia during pneumoperitoneum, prompting a fluid bolus to maintain stroke volume and prevent hypotension
Studies have shown that GDFT can reduce postoperative complications, including …
acute kidney injury and prolonged hospital stay
If significant cardiovascular disease, invasive hemodynamic monitoring with a …. may be necessary to guide fluid therapy and inotropic support
pulmonary artery catheter
or
TEE
Advanced heart failure undergoing laparoscopic liver resection. Why use TEE?
real-time information about:
- ventricular filling,
- wall motion abnormalities,
- adequacy of fluid resuscitation
By monitoring the fuctional level of the ___, we can adjust preload and afterload in response to changes in hemodynamic status
left ventricle
Why are sevoflurane and desflurane commonly used for lap surgery?
rapid onset and offset
(quick emergence)
How do volatiles affect HD status?
- dose-dependent decreased contractility
- may exacerbate hypoTN if reduced cardiac reserve
If reduced cardiac reserve, which may be the better choice?
A) TIVA with propofol
B) Volatiles
A) TIVA w prop
propofol provides stable hemodynamics, reduces PONV, and avoids the myocardial depressant effects of volatile agents
History of severe postop delirium, undergoing robotic-assisted laparoscopic prostatectomy. Whats your plan?
TIVA with propofol and remifentanil
to minimize the risk of delirium while maintaining stable hemodynamics
EEG to avoid over-sedation
Venous gas embolism
- rare but serious complication of laparoscopic surgery
- When CO2 enters the venous system, it can travel to the right atrium and ventricle, causing a “gas lock” that obstructs pulmonary blood flow and results in rapid cardiovascular collapse
Venous gas embolism is more common with which procedures?
involving highly vascular organs such as the liver or spleen
clinical signs of venous gas embolism
- sudden drop in end-tidal CO2
- hypotension
- cyanosis
- characteristic “mill-wheel” murmur
T/F:
During laparoscopic liver resection, the patient becomes hypotensive and cyanotic. The etCO2 has suddenly increased. This is highly suspcious of venous gas embolism.
False
sudden drop in end-tidal CO2
Immediate management of an embolism involves what? What about in severe cases?
stopping CO2 insufflation, placing the patient in the left lateral decubitus position (Durant maneuver),
administering 100% oxygen.
In severe cases, aspirating the gas through a central venous catheter or performing cardiopulmonary resuscitation (CPR) may be required. Early recognition and intervention are critical to preventing fatal outcomes.
What is Capnothorax? What is it associated with?
Capnothorax is another possible complication of laparoscopic surgery, particularly during procedures near the diaphragm.
CO2 can leak into the pleural space, causing lung collapse and leading to hypoxemia and increased airway pressures. If not recognized promptly, this can progress to tension pneumothorax, where the increased intrathoracic pressure impedes venous return and causes cardiovascular collapse.
What all is involved in the management of a capnothorax?
immediately stop insufflation and decompress the pneumothorax (needle thoracostomy or chest tube)
reducing pneumoperitoneum may alleviate the capnothorax without the need for invasive intervention.
Close monitoring of airway pressures and oxygenation is essential to detect this complication early.
Occurs when CO2 escapes into the subcutaneous tissues during laparoscopic surgery.
Subcutaneous emphysema
It presents as swelling and crepitus, typically around the neck, chest, and face.
SubQ emphysema
Is subQ emphysema generally benign? What can it lead to?
While generally benign, subcutaneous emphysema can sometimes lead to significant hypercarbia if large amounts of CO2 are absorbed.
In rare cases, the CO2 can track into the mediastinum, causing pneumomediastinum or pneumopericardium, which can result in cardiovascular compromise.
describe the management for subcutaneous emphysema.
reducing pneumoperitoneum pressure, stop insufflation if necessary, supportive care
Mostly resolves spontaneously as CO2 is absorbed, but monitor for signs of respiratory or cardiovascular compromise!
The postop phase of laproscopic surgery requires careful attention to:
respiratory and cardiovascular stability,
pain control and the
prevention of thromboembolic complications.
Patients with___________ are at higher risk for postoperative hypoxemia, hypercarbia, and atelectasis.
significant respiratory disease, obesity, or obstructive sleep apnea (OSA)
In patients with OSA or obesity, the application of CPAP or BiPAP postoperatively can be highly effective in _______ and _______
preventing airway collapse and improving oxygenation.
In patients with significant respiratory compromise, frequent ________ monitoring may be necessary to guide further ventilatory support.
arterial blood gas
what 3 interventions are critical for preventing atelectasis and improving postoperative lung function?
Early mobilization, aggressive pulmonary toilet, and the use of incentive spirometry
___________ is the cornerstone of postoperative pain management in laparoscopic surgery, minimizing the use of opioids while providing effective pain relief.
Multimodal analgesia
Regional anesthesia techniques, such as _____ or _______, can provide excellent analgesia for abdominal incisions.
transversus abdominis plane (TAP) blocks or rectus sheath blocks
These blocks can be combined with non-opioid analgesics, such as acetaminophen and NSAIDs, to provide a comprehensive approach to pain control without the risks associated with opioids, such as respiratory depression and PONV.
__________ is a significant risk after laparoscopic and robotic surgeries, particularly in patients undergoing prolonged surgery in Trendelenburg position, where venous stasis can occur.
Venous thromboembolism (VTE)
what interventions are essential in high-risk patients to reduce the risk of deep vein thrombosis (DVT) and pulmonary embolism (PE)?
Early mobilization, mechanical thromboprophylaxis with intermittent pneumatic compression devices, and pharmacological thromboprophylaxis with low-molecular-weight heparin (LMWH)
Robotic surgery introduces additional complexities, particularly in terms of _____ and _____
patient positioning and access.
Once __________, patient access is severely limited, making it difficult to intervene in emergencies.
the robotic arms are docked
Careful preoperative planning and coordination with the surgical team are essential to ensure that _________
all necessary emergency equipment and personnel are readily available.
The steep Trendelenburg position commonly used in robotic pelvic surgeries increases the risk of :
ocular injuries, facial edema, and increased intracranial pressure.
________ is essential to prevent corneal abrasions and other ocular injuries.
Intraoperative ocular protection, such as eye lubrication and taping
Monitoring for signs of increased intracranial pressure, such as __________, is critical in patients with pre-existing neurological conditions.
changes in pupillary response or cerebral oximetry
T/F The chapter discusses the practice of actively warming and humidifying insufflated CO2 gas during laparoscopic surgery. However, recent research indicates that insufflation with heated and humidified CO2 gas compared to cold and dry gas has not shown significant advantages in preventing hypothermia, and standard hypothermia prevention methods are still preferred in most cases
TRUE
T/F newer studies advocate for more restrictive fluid therapy, suggesting that high-volume fluid loading may increase the risk of complications, including edema and prolonged recovery
TRUE
the latest evidence indicates a need for caution in the use of COX-2 inhibitors due to potential _______ risks.
cardiovascular
acetaminophen, when used in combination with NSAIDs, is generally regarded as ______
as safe but is preferred at lower doses for patients with liver conditions
NTG should be titrated carefully to avoid excessive hypotension, especially in patients who may already experience hemodynamic changes due to ____________
pneumoperitoneum.
Other vasodilators such as ____ or _______ are sometimes preferred in laparoscopic surgery, as they provide more stable blood pressure control with potentially fewer side effects on myocardial oxygen demand.
nicardipine or esmolol
There is an increased focus on the judicious use of NTG, as its potential to induce rapid vasodilation can be problematic in patients with ____________
compromised cardiac function, especially during steep Trendelenburg positioning, where venous return is already affected.
Newer guidelines suggest that N2O should be used with caution in which situations?
particularly in laparoscopic surgery, where it may worsen intestinal distension, and in patients at high risk for PONV or those undergoing lengthy procedures where air-filled cavities may pose additional risks
Current evidence supports avoiding both fluid overload and under-resuscitation, with____________ to guide fluid administration based on patient-specific needs
advanced hemodynamic monitoring (e.g., esophageal Doppler)
Evidence-based guidelines now emphasize more comprehensive monitoring of intraocular pressure (IOP) and recommend _________ during prolonged surgeries to reduce the risk of ocular complications
fluid restriction, head elevation post-surgery, and the use of protective measures like eye patches
Current guidelines suggest an increased use of ____________ to minimize opioid-induced PONV and postoperative respiratory depression
regional anesthesia, non-opioid analgesics, and preemptive multimodal approaches
current evidence advises caution with deep NMB, particularly concerning residual paralysis, which can increase the risk of _________. T
postoperative respiratory complications
The importance of ______ and ________ is emphasized to prevent incomplete neuromuscular recovery
monitoring using objective measures (e.g., train-of-four monitoring) and the appropriate use of reversal agents like sugammadex
In conclusion, anesthesia for laparoscopic and robotic surgeries requires a comprehensive understanding of the physiological changes induced by:
pneumoperitoneum, patient positioning, and CO2 absorption.
By applying advanced intraoperative management strategies, such as _______________, anesthesiologists can mitigate many of the challenges associated with these procedures.
goal-directed fluid therapy, ventilatory adjustments, and real-time hemodynamic monitoring
Through _____________, we can optimize patient outcomes in these challenging cases.
anticipation of complications, such as venous gas embolism and capnothorax, and the use of best practices for pain management and postoperative care
