Lap & Gyn (Part 2)

Question 1

T/F:
Everyone will have some sort of atelactasis after insufflation.

Answer 1

True
instruct them to take deep breaths after surgery

Question 2

Lap Surgery
Healthy vs Compromised patients

Answer 2

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

Question 3

Recommended setting for single lung ventilation

Answer 3

• Vt 390-490
• PEEP 8-10
• RR 16-17 (faster to lower etCO2)
• dont exTT if CO2 abnormally high
• obtain gas if needed

Question 4

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

Answer 4

• 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

Question 5

Volume-controlled ventilation (VCV) ensures consistent tidal volumes, which is important for….

Answer 5

maintaining adequate alveolar ventilation in the face of reduced lung compliance.

Question 6

Cons of VCV ventilation for insufflation

Answer 6

often leads to high peak airway pressures

esp Trendelenburg or obese

Question 7

You have high peak pressures on VCV. Why switch to PCV?

Answer 7

limits peak airway pressures while allowing tidal volumes to fluctuate based on lung compliance

Question 8

T/F:
Volume control ventilation will allow tidal volumes to fluctuate based on lung compliance.

Answer 8

False
PCV

Question 9

Lap Surgery

When would you want to obtain a gas prior to exTT?

Answer 9

unable to correct introp etCO2 of 50-60 without aggressive Vt and PEEP

Question 10

When to use permissive hypercapnia as it may be necessary to avoid the risk of barotrauma

Answer 10

COPD and other significant respiratory pathology

Question 11

significant respiratory pathology (ex: severe COPD) have high baseline ___ levels due to impaired ___ clearance

Answer 11

high baseline PaCO2

impaired CO2 clearance

Question 12

T/F:
The CRNA must normalize the etCO2 in a patient with COPD.

Answer 12

False
normalizing PaCO2 through aggressive ventilation can lead to dangerously high airway pressures and ventilator-induced lung injury (VILI)

Question 13

You’ve decided to employ permissive hypercapnia in your severe emphysema patient. What does this require?

Answer 13

allowing PaCO2 to rise to 55-60

provided that oxygenation is maintained and acidosis is not severe

Question 14

Which patients are at risk for postop resp complications from lap surgery? What complications may occur?

Answer 14

lung disease, obese, OSA

atelectasis, hypoxemia, and hypercarbia

To minimize these risks, CPAP or BiPAP immediately postop can be highly effective.

Question 15

preventing atelectasis and improving postoperative lung function

Answer 15

• Early mobilization
• aggressive pulmonary toilet
• incentive spirometry
• CPAP, BiPAP

Question 16

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

Answer 16

1. postoperative CPAP to prevent airway collapse and improve oxygenation
2. close monitoring in a postop care unit with frequent ABG may be necessary to guide further management

Question 17

Intraoperative management during laparoscopic and robotic surgery involves a delicate balance of

Answer 17

fluid therapy,
ventilatory support,
monitoring for complications

Question 18

effects of pneumoperitoneum and positioning are often transient, but their effects can be profound, particularly in…

Answer 18

patients with significant comorbidities

Question 19

T/F:
One of the key challenges during laparoscopic surgery is managing fluid therapy in the context of the hemodynamic changes induced by pneumoperitoneum.

Answer 19

True

Question 20

pneumoperitoneum
HD effects

Answer 20

• increased intra-abdominal pressure reduces venous return = ↓ preload & CO
• increases SVR, which raises afterload
  ⬇️
  significant hypotension
  esp if impaired cardiac function

Question 21

Goal-directed fluid therapy (GDFT)

Answer 21

• 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

Question 22

Studies have shown that GDFT can reduce postoperative complications, including …

Answer 22

acute kidney injury and prolonged hospital stay

Question 23

If significant cardiovascular disease, invasive hemodynamic monitoring with a …. may be necessary to guide fluid therapy and inotropic support

Answer 23

pulmonary artery catheter
or
TEE

Question 24

Advanced heart failure undergoing laparoscopic liver resection. Why use TEE?

Answer 24

real-time information about:

• ventricular filling,
• wall motion abnormalities,
• adequacy of fluid resuscitation

Question 25

By monitoring the fuctional level of the ___, we can adjust preload and afterload in response to changes in hemodynamic status

Answer 25

left ventricle

Question 26

Why are sevoflurane and desflurane commonly used for lap surgery?

Answer 26

rapid onset and offset

(quick emergence)

Question 27

How do volatiles affect HD status?

Answer 27

• dose-dependent decreased contractility
• may exacerbate hypoTN if reduced cardiac reserve

Question 28

If reduced cardiac reserve, which may be the better choice?
A) TIVA with propofol
B) Volatiles

Answer 28

A) TIVA w prop

propofol provides stable hemodynamics, reduces PONV, and avoids the myocardial depressant effects of volatile agents

Question 29

History of severe postop delirium, undergoing robotic-assisted laparoscopic prostatectomy. Whats your plan?

Answer 29

TIVA with propofol and remifentanil
to minimize the risk of delirium while maintaining stable hemodynamics

EEG to avoid over-sedation

Question 30

Venous gas embolism

Answer 30

• 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

Question 31

Venous gas embolism is more common with which procedures?

Answer 31

involving highly vascular organs such as the liver or spleen

Question 32

clinical signs of venous gas embolism

Answer 32

• sudden drop in end-tidal CO2
• hypotension
• cyanosis
• characteristic “mill-wheel” murmur

Question 33

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.

Answer 33

False
sudden drop in end-tidal CO2