Lap + GYN + Robots - Exam 6 Flashcards
Most complications from lap procedures occur during which two phases of the surgery?
-initial entry into abdomen
-creation of pneumoperitoneum
Leading cause of morbidity and mortality in lap cases:
severe vascular injury
followed by injury to bowel (usually with umbilical trocar
Lap cases can be done with an _ or _ or _ _ - _ entry technique
open (Hasson)
closed
left upper-quadrant (Palmar point)
Pts at risk for injury from umbilical entry-related lap injuries include:
-thin
-obese
-those with abdominal adhesions
-should have open (Hasson) or LUQ (palmar point) entry techniques instead
The closed entry technique for lap cases involves the use of a _ -loaded Veress needle to pierce the abdominal wall at its thinnest point, either the _ or _ region
spring-loaded
infraumbilical or intraumbilical
An intraabdominal pressure of _ mmHg or less indicated a properly placed Veress needle
10
T/F An appropriate nonflammable gas, usually carbon monoxide is used to insufflate the abdomen, lift the abdominal wall, and create space between it and underlying organs.
false, CO2, not CO
Purpose of trocar in lap cases:
helps surgeon pass instruments into abdomen
T/F Trocars are inserted blindly or under direct vision after insufflation during lap cases.
true
T/F Rate of injury increases after mult attempts of placing trocar. If more than 2-3 attempts have been made, alternative techniques should be used
true
The open entry technique for laps involves an incision of _ to _ mm midline _ incision which begins in the _ border of the umbilicus and extends thru the _ _ and underlying fascia
1 - 2.5mm
vertical
lower
subcut tissue
Goal of open entry technique for laps:
-minimize risk of damage to bowel and vasc
CO2 is the perfect insufflating gas because:
-colorless
-doesn’t explode
-cheap
-easily removed by body
-nontoxic
-minimal risk of air embolism
In some pts, the _ _ that coincides with inducing a pneumoperitoneum can stimulate a _ -mediated bradycardia which can be fixed by releasing it and preventing pressures from increasing beyond _ mmHg or by giving _ or _
peritoneal stretch
vagally
16mmHg
Glyco or Atropine
Typically, increases in _, _, and _ are sustained while the abdomen is insufflated, and this is likely due to compression of _ _, causing release of neuroendocrine hormones such as _ or _
MAP, SVR, and HR
intrabdominal vessels
renin or vasopressin
_ and _ increase regardless of whether insufflation pressures are 12-20mmHg
MAP and SVR
Pneumoperitoneum hemodynamic changes
5mmHg
HR: inc
MAP:inc
SVR: inc
venous return: -/dec
CO: -/dec
-no sig effects on renal or resp. system
Pneumoperitoneum hemodynamic changes
10mmHg - CV changes
HR: inc
MAP: inc
SVR: inc
venous return: -
CO: -/inc
Pneumoperitoneum hemodynamic changes
10mmHg - Renal + Resp
GFR: dec
UO: dec
EtCO2: -/inc
PCO2: inc
Art. pH: -/dec
Pneumoperitoneum hemodynamic changes
20mmHg - CV changes
HR: -
MAP: inc
SVR: inc
venous return: -
CO: -/dec
Pneumoperitoneum hemodynamic changes
20mmHg - renal + resp changes
GFR: dec a lot
UO: dec a lot
EtCO2: -/ inc
PCO2: inc
Art pH: dec
Pneumoperitoneum hemodynamic changes
40mmHg - CV changes
HR: dec
MAP: inc
SVR: inc
venous return: dec
CO: dec
Pneumoperitoneum hemodynamic changes
40mmHg - renal and resp changes
GFR: dec a lot
UO: dec a lot
EtCO2: inc
PCO2: inc
Art pH: dec
Which has larger effect on central pressures, insufflation or position changes for lap?
position changes (steep trend)
Steep trend causes a large increase in CVP because it eases _ _ and increases _ pressure at the level of the _ _ _
venous return
hydrostatic
external auditory meatus
T/F Reverse trend increases preload, which raises CO
false, decreases both
Why does SV decrease during a pneumopeitoneum?
decreased venous return
-NOT depressed myocardial function
Compression of aorta, production of neurohormonal factors, and activation of the RAAS system may not only raise _, but also have a _ effect on myocardial function
SVR
depressant
Variable impact on CO/ CI from a pneumoperitoneum is dependent on multiple factors such as:
-volume status
-use of PPV
-insufflation pressures
-ability of pt’s HR to increase to compensate changes
Pneumoperitoneum can cause significant _ in LVEDP which can _ cardiac function if not accompanied by sufficient _ in HR
decrease
decrease
increase
Pneumoperitoneum can increase _ _ (QTd), which _ risk of arrhythmias and cardiac effects
QT dispersion (reflects ventricular instability)
increase
Reverse trend position does what to CO?
decreases, less venous return
Cumulative effects of CO2 in pneumoperitoneum and reverse trend position can cause moderate _ in CO, significant _ in filling pressures and afterload in sick pts.
decrease
increase
Elderly pts receiving pneumoperitoneum have greater _ in CVP and _ in MAP compared to younger pts
increases
decreases
Increased abdominal pressure shifts the _ expiratory position of the diaphragm _ which decreases _, _, and _, which cause atelectasis and make ventilation difficult.
end
cephalad
FRC, FEV-1, and FVC
When MV is fixed, pneumoperitoneum is associated with increases in _ and _ with or without accompanying acidosis. This can cause pulmonary _ and cardiac _.
PaCO2 and EtCO2
vasoconstriction dysrhythmias
What increases PaCO2 during pneumoperitoneum?
CO2 absorption thru peritoneal serosa from increased intrabdominal pressure
Is increased PaCO2 with acidosis from insufflation metabolic or respiratory?
respiratory - won’t have increased LA or H+, just increased PaCO2
increased PaCO2 needs to be offset by increased RR (linda)
-increased MV but keep within 6-8mL/kg IBW
Max absorption of CO2 is noted with intrabdominal pressure of _ torr/mmHg
10mmHg
PaCO2 levels plateau approx. _ mins after insufflation.
40 min
T/F During a lap case, your pt’s PaCO2 rapidly increases and has exceptionally high sustained CO2 levels; they most likely have experienced normal intraperitoneal insufflation.
False,
extraperitoneal insufflation/ subcut absorption
T/F It is possible for a pt to experience orbital emphysema and pneumopericardium after extraperitoneal absorption of CO2.
true :(
Subcutaneous emphysema from extraperitoneal insufflation
-risk factors (5 big ones)
EtCO2 > 50mmHg
Operative time >200min/ 3.5hr
6+ surgical ports/cannulas
High insufflation pressures (>15mmHg)
Extraperitoneal dissections
multiple attempts at entry
Poor skin/fascial seal around ports
Laparoscope used as lever
Cannula acting as fulcrum
Repetitive movement damaging tissue
Stressed angulation
Gas dissection
Red flag signs of subcut emphysema:
-crepitus
-hypercarbia
-increased EtCO2
-decreased lung compliance
-arrhythmias
-HTN
How to manage subcut emphysema:
-tell surgeon to decrease or stop pneumoperitoneum
-DC N2O
-100% FiO2
-look for pneumothorax
-increase MV (RR actually) to treat hypercarbia
-monitor EtCO2 and PaCO2
-monitor chest wall and lung compliance
-assess airway to rule out compression prior to extubation
Which region of lungs can experience atelectasis during insufflation?
dependent
-perfusion to the nonventilated alveoli cause a shunt with impaired oxygenation and CO2 elimination, increasing arterial-EtCO2 difference
Increased intraabdominal pressure decreases pulmonary compliance in supine pts by ~ _ %
43%
Increased V/Q mismatching and changes in oxygenation during lap cases are most likely more dependent on which factors, effects of anesthetics or pneumoperitoneum?
anesthetic effects BC ** they attenuate or inhibit hypoxic pulmonary vasoconstriction (HPV) reflex ** which offsets VQ mismatch from pneumoperitoneum
Pulmonary function changes associated with pneumoperitoneum:
INCREASES:
PIP
Intrathoracic Pressure
DECREASES:
VC
FRC
Pulm compliance
Anesthesia + pneumoperitoneum have an additive effect on reducing _ and _ _
FRC and pulm compliance
Pulm compliance drops by _ % and peak plateau pressure increases by _ % in steep trend position with pneumoperitoneum
pulm compliance dec 50%
peak plateau inc 50%
Which position counteracts effects of pneumoperitoneum and improves diaphragmic function?
reverse trend
Endobronchial intubation can occur with pneumoperitoneum by _ the distance of the tip of the EET to the _
shortening
carina
Cephalad displacement of the diaphragm compresses the lungs and moves the position of the carina _, moving the ETT _ (cephalad/caudad)
up
caudad
Tube displacement occurs within _ mins of pneumoperitoneum creation. What can be done to check for displacement?
10 mins
listen to BS (reconfirm placement)
In the trend position, a _ - _ % increase in MV is needed to maintain pneumoperitoneum and prevent acidosis
20-30%
Which is better during a pneumoperitoneum in the trend position to control art pH, PCV or VCV?
PCV
-easier to ventilate, generating less max peak pressures and increased mean airway pressures
-watch Vt when pneumo pressure is released!!!
Lung protection strategies:
6-8ml/kg IBW MV
plateau pressures below 16cmH20
lowest driving pressure possible
moderate PEEP
recruitment maneuvers Q 30 min
Why is EtCO2 for a COPD pt in trend position with pneumoperitoneum not accurate?
large arterial- EtCO2 gradient is compounded by those 3 factors
-measure directly via PaCO2 via ABG or PtCO2 (noninvasive)
After lap cases, a slight _ respiratory pattern occurs due to which 3 factors?
restrictive
-pain
-diaphragmic dysfunction
-residual effects of anesthetic
If lap case is long, CO2 can be absorbed into _ and _ _. This allows it to be excreted back into pt for hours after.
bone and skeletal musc
Which physiologic conditions are at greatest risk for decompensation due to physiologic changes of laparoscopy?
increased metabolic rate (sepsis)
COPD
large vent dead space
decreased CO
Renal effects from pneumoperitoneum:
-inc CrCl
-dec renal BF
-dec UO
-oliguria
-transient renal injury (hypoperfusion of renal cortex)
-renal oxidative stress -> tubular injury (only if intraabdominal pressures >15mmHg)
-release of ADH, aldosterone, renin
Hepatic effects from pneumoperitoneum:
-ischemia 2/2 production of O2 free radicals
-bacterial translocation
-increased lipid and protein oxidative substances -> damage splanchnic tissue
-elevated liver enzymes
Immune effects from pneumoperitoneum:
-alters conc of certain cytokines within the peritoneum (decreases local immune response)= possible to cause cancer
Entry-related injuries for lap cases include:
-intestinal, vascular, and urinary tract injuries
-CO2 embolism
What factors increase laparoscopic injury risk? (7)
- Body habitus
- Anatomic anomaly
- Prior surgery
- Surgical skill
- Degree of abd elevation
- patient position
- Volume of gas
Vascular injury during lap s/s (3)
- Aspiration of blood through Veress needle
- Free intraperitoneal blood
- Unexplained hypotension and tachycardia
What must happen to successfully treat laparoscopic vascular injury? (not anesthesia/med related)
Conversion to open lap
Visceral injuries in lap cases are hard to recognize and may go on to cause _, _, _ _ , and MODS in untreated pts.
sepsis
peritonitis
resp distress
How can you test for urinary tract damage?
Injection of methylene blue dye via catheter
What is the best pressure for the trocar placement?
25mmHg
What is the actual incidence of gas embolism during lap surgery?
65-100%
Why is CO2 used instead of helium?
high incidence of subcutaneous emphysema and life-threatening gas embolism with helium
Gas embolism can occur anytime open vessels have an intravascular pressure that is _ intraabdominal pressure or with erroneous placement of a _ _ or a _ into vessel
below
veress needle
trocar
Cardiovascular patho of gas embolism
1. Large volumes of gas move to the _ side of the heart, entering _ circulation
2. Gas lodges in pulm _ tract causing increased _, _ failure, decreased pulm _ _ .
3. This causes decreased LV _, decreased _, asystole and cardiovascular collapse
- right, pulmonay
- outflow, PAP, RV, venous return
- preload, CO
S/s gas embolism
-Loss of etCo2 or acute decrease
-Hypotension
-Hypoxia
-Increased etN2
-CV collapse
-Mill wheel murmur(only when volumes of 2mL/kg entrained :[ )
-O2 sat down
-Increased PAP
-Dysrhythmia
-Cyanosis
-Pulmonary edema
-Wheezing, rales
-Physical detection
Best technique for dx gas embolism:
TEE
Treatment of gas embolism
-Deflate abd, halt N2O
-Flood sterile saline on field
-Durant maneuver (position pt in L lat decub.)
-Aspirate embolism through CVP
-Support BP
T/F Low SVR increased risk of venous gas embolism
false, low CVP does
-adequate hydration is important
What can gas migration from the abdomen during lap cause?
Pneumothorax (UL or BL)
Pneumomediastinum
Pneumopericardium
What kind of lap case would most likely cause gas to enter the thoracic cavity?
lap esophageal cases
Pneumothorax can happen during lap cases from _ 2/2 _ airway pressures and _ pulm compliance from insufflation.
barotrauma
increased
decreased
T/F Pneumothorax from CO2 insufflation is always an emergency and requires placement of a chest tube
false
-usually resolves quickly without intervention
T/F Pneumothorax from barotrauma causing ruptured bleb usually resolves spontaneously without intervention
false,
EMERGENT, needs surgical decompression and chest tube!!!
Factors that are predictive of pneumothorax include:
-max EtCO2 >50
-operative time >200 min or 3.5 hr
-use of 5+ entry points
-lap mobilization of esophagus
-operator inexperience
Is subq emphysema risk worse with direct, indirect approach or same?
same
What is concerning about severe subq emphysema of head?
possibility of severe airway swelling, inability to reintubate if extubated too early
pt may need to be left intubated
Risks with other gases for insufflation:
O2- combustion
N2O- combustion
Air- combustion
Helium-insoluble, possibility of large gas embolism
Cons to using CO2 as insufflation gas:
-resp acidosis + hypercarbia
-peritoneal and diaphragmic irritant= known to cause postop shoulder pain
Cons of regional anesthesia over general for lap
Post-op shoulder pain (poorly managed with regional)
Patient discomfort
More hypotension (sympathetic blockade)
Anesthesia-specific adverse event of laparoscopy? (postop, there is an increased incidence)
PONV
Which produces less PONV: TIVA or inhaled anesthetics?
TIVA
3 Major categories of pain postop lap? Majority of pain from?
- Incisional pain (parietal)
- Deep intraabdominal pain (visceral)
- Shoulder pain (referred visceral pain)
-Majority pain from visceral on DOS
-shoulder pain on postop day 1
The peritoneum and viscera convey unpleasant sensations and _ reactions to injury via the _ nerve, causing painful and nonpainful sensations.
autonomic
vagus
Intraabdominal CO2 contributes to postop pain by decreasing intraperitoneal _ and causing irritation of the _ nerve
pH
phrenic
Methods that reduce shoulder tip pain (STP) for postop lap cases:
-recruitment maneuvers
-extended assisted ventilation
-active aspiration of intraabdominal gas
(most significant factor=technique of releasing pneumoperitoneum)
Classification of robotics systems?
Assist(AESOP) and telemanipulators (daVinci and Senhance)
-Based on how much “hands-on” control is required
Da Vinci system components?
Vision system, surgeon console, patient-side cart
How many degrees of freedom does the EndoWrist have?
7
-3 arm motions (in-ou, up-down, side-side)
-3 wrist movements (side-side,left, right yaw)
-pitch
-rotation
Where must the surgeon’s head be in order for the system to function?
in the viewer
-2nd surgeon must be present to ensure proper protocols and adjust camera
Anesthetic plan for robot cases must consider these 7 factors:
-prolonged surgical times
-spatial restrictions
-inability to alter pt position once docked
-physiological changes in extreme positions
-risk of postop vision loss (POVL)
-consequences of pneumoperitoneum
-ERAS protocols
What spatial restriction is of particular concern in robot cases? Other concerns?
-Inability to reach patient during emergencies
-inability to reposition emergently
-Padding between instruments and robot
Factors beyond anesthesia’s control that prolong surgical time with robot cases:
-operator inexperience
-surg complexity
-time required for positioning/docking
Which has a shorter robot undocking time, daVinci or Senhnce?
Senhance
Minimum preparation (patient) for robotic surgery?
- 2 Large bore IVs
- Arterial line if rapid blood loss or serial labs are expected
- T/S for at least 4 units of blood
- Invasive monitoring
- Emergent undocking protocol
- 2 blood pressure cuffs/2 pulseox
What position is most commonly used for robotic procedures?
Steep trendelenburg
-Head down 40-45 degrees
-must document checking pt position Q15 or when robot/ OR table is moved
Changes associated with Steep Trend position
-CV
INCREASED:
-MAP
-CVP
-PAWP
-SVR/afterload
NO CHANGE:
-HR
-SV
-MVO2
Changes associated with Steep Trend position
-Resp
INCREASED:
-airway resistance
-peak airway pressure
-plateau pressure
-EtCO2
-upper airway edema
DECREASED:
-compliance
-VC
-FEV1
Physiologic changes with steep trend
-Neuro
INCREASE:
-ICP
-Hydrostatic pressure gradient
-IOP
-Cerebrovascular resistance
DECREASE:
-Cerebral venous drainage
UNCHANGED:
-Regional cerebral oxygenation
-Cerebral perfusion pressure
When to recheck BS with robot cases/lap cases?
-after insufflation
-after repositioning/steep trend
Overall effects of increased filling pressure and SVR during steep trend=
prolonged isovolumetric relaxation time
Which part of lungs experience atelectasis during pneumoperitoneum and steep trend?
dorsal part of lungs
Which vent setting makes a big difference in improving compliance, oxygenation, and homogenous ventilation ability?
PEEP 15cm H2O
Respiratory changes due to steep trendelenburg are raised in which patient disease group?
COPD
How long can lung atelectasis due to reductions in FEV1 and vital capacity continue on for in COPD patients?
5 days
What are most of the prolonged changes to respiratory physiology r/t steep trendelenburg caused by?
airway edema
-can last up to 2 hr postop
ICP raises more than _ mmHg in the steep trend position.
20mmHg
-this is due to increases in MAP and decreased venous drainage
The ICP changes due to Steep Trens positioning are directly related to which other vital sign?
MAP increase
Major causes of POVL (disease)?
AION - anterior ischemic optic neuropathy
PION - posterior ischemic optic neuropathy
CRAO - central retinal artery occlusion
Cortical blindness
Risk factors for AION
Risk factors for PION
AION:
-Cardiac, major vascular, spine
PION:
-Prone, steep trendelenburg, high venous pressures
S/S AION and PION:
sudden onset of painless vision loss and visual field deficits, seen on emergence of anesthesia
What causes CRAO and cortical blindness?
Procedures with high embolic load
Severe hypotension
Direct global compression
Independent risk factors for POVL?
-Male gender
-Obesity
-Prolonged anesthetic duration
-Prone
-Greater EBL
-HoTN
-Lower percentage of colloid replacement
What two mechanisms increase risk for POVL for robotic surgery?
Increased venous congestion and interstitial edema
Prevention of POVL:
-minimize surgical time
-staged procedures if possible
-minimize EBL
-decrease venous congestion
-HOB at or above level of heart
-colloids
discuss risks w pt
Which medications might help reduce IOP and reduce risk of POVL in steep trend?
-topical beta blockers
-carbonic anhydrase inhibitors (dorzolamide-timolol)
ERAS preoperative guidelines, overall goal
prevent catabolic state associated with fasting/dehydration
ERAS intra/postoperative guidelines (overall goal)
maintain euvolemic state
fast track pt into early ambulation/feeding
Mechanism by which ERAS improves patient outcomes?
Stress reduction
-Faster return of GI fx
Perioperative fluid overload, effects postoperatively
- Increase morbidity
- Postop ileus
-Hypoproteinemia -> delayed gastric emptying
What is the carbohydrate drink for ERAS
12.5% maltodextrin 100g night before, then 50g 2-3hr before induction
-gatorade
What are the effects of overnight fasting (physiologic)?
Inhibits insulin secretion:
-Insulin resistance
Promotes release of cortisol and glucagon:
-Glycogen depletion
-Protein breakdown
Infusion rate of isotonic crystalloid rate for intraoperative period ERAS?
3 +/- 2 mL/kg
Should you continue IV fluids in PACU?
no, DC unless otherwise indicated
PONV treatment based on # of nausea risk factors
Female
hx motion sickness/PONV
non smoker
perioperative narcotics
1-2 factors: 2 antiemetics
3-4 risk factors: 2-3 anti-emetics + TIVA and opioid-sparing strategies (TAP blocks, regional, etc)
D+C
-indications
-anesthesia
I: uterine bleed, dysmenorrhea, infertility
A: LA, SAB = T10, GA
D+C
-position + nerve risk
-EBL
Dorsal lithotomy with allan stirrups
-CPN, obturator, saphenous, femoral n = foot drop
blood: significant
D+C
-complications
-considerations
vasovagal (atropine), uterine atony, uterine perf
-keep deep during dilation
-preop H+H and HCG
-RSI-ETT>1
Suction Curettage
-indications
-anesthesia
I: pregnancy termination <12 wks
A: none :’( medical termination
Suction Curettage
-position + nerve risk
-EBL
Dorsal Lithotomy with allan stirrups
-CPN, obturator, saphenous, femoral n = foot drop
blood: 10-400mL
Suction Curettage
-complications
-considerations
incomplete abortion
sepsis (retained placenta)
-seizure during LA injection
-infection/fever
-be nice, this is a sensitive time
D+E
-indications
-anesthesia
I: pregnancy termination >16 wk
A: GA
D+E
-position + nerve risk
-EBL
Dorsal Lithotomy + allan stirrups
-CPN, obturator, saphenous, femoral n = foot drop
blood: 300-500mL
D+E
-complications
-considerations
endometriosis
uterine perf (excessive postop pain)
-suction +forceps (keep MAC <1 to lower risk of uterine atony / bleed)
-be nice, this is a sensitive time
Ectopic Pregnancy Surgery
-indications
-anesthesia
I: fallopian tubes usually, pain, bleeding positive HCG
A: medical, methotrexate; surgical GA bc this is awful emotionally
Ectopic Pregnancy Surgery
-position + nerve risks
-EBL
EBL: significant (rupture)
Ectopic Pregnancy surgery
-complications
-considerations
hemorrhage
severe postop pain
-transvaginal US and IVF prior to induction
-be nice, this is a sensitive time
Cervical Cerclage
-indication
-anesthesia
I: cervical incompetence ~14-18wks
A: SAV (T10) and therapeutic commmunication
Cervical Cerclage
-position + nerve risk
-EBL
Lithotomy LEFT LATERAL pelvic
Trend
-CPN injury
blood: minimal
Cervical Cerclage
-complications
-considerations
cervical rupture
chorioamnionitis
preterm labor
spont abortion
-tocolysis - indomethacin
-IVF before SAB
-RSI if >16wks
-extubate awake
Staging Lap
-indication
-anesthesia
I: Cancer ( open explore or debulk and confirm)
A: LA + MAC or GASta
Staging Lap
-position + nerve risk
-EBL
EBL: significant
Staging Lap
-complication
-considerations
hemorrhage
lymphadenectomy
vasc injury
ascites (RSI)
chemo effects
-expect fluid shifts (ascites/peritoneal)
-endocrine diseases too?
-stress steroid?
Ex Lap
-Indication
-anesthesia
I: diagnostic
A: GA +ETT
Ex Lap
-position + nerve risk
-EBL
open-supine
lap-dorsal
lithotomy
-
EBL: significant
open>lap
Ex Lap
-complications
-considerations
hemorrhage
thrombophlebitis
pneumoperitoneum
Hysteroscopy
-indication
-anesthesia
I: abnormal uterine bleeding, biopsy, IUD
A: LA + MAC (symptoms ) or GA
Hysteroscopy
-position + nerve risk
-EBL
EBL: minimal
Hysteroscopy
-complications
-considerations
TURP LIKE SYNDROME (pulm edema, cerebral edema)
vasovagal (atropine)
gas embolism
-check BMP preop
-stop >500mL fluid
-LA pericervical
-toradol for pain
Hysterectomy - Vaginal
-indication
-anesthesia
I: uterus removal, preferred method
A: LA + MAC, RA (SAB ~ T5) or GA
Hysterectomy - Vaginal
-position + nerve risks
-EBL
Doral Lithotomy
-femoral n
EBL: minimal
Hysterectomy - Vaginal
-complications
-consideration
vasovagal (atropine)
hemorrhage
lymphadenectomy
vasc injury
ascites (RSI)
-
Hysterectomy - Abdominal (Lap/Robot)
-indications
-anesthesia
I: large uterus, bony pelvis, adhesions, cancer
A: GA + ETT + NGT
Hysterectomy - Abdominal (Lap/Robot)
-position + nerve risk
-EBL
Steep Trend
-fem nerve
EBL: minimal
Hysterectomy - Abdominal (Lap/Robot)
-complications
-considerations
vasovagal (atropine)
hemorrhage
lymphadenectomy
vasc injury
ascites (RSI)
-MR is required, no movement
Hysterectomy - TAH-BSO
-indications
-anesthesia
I: uterus, cervix, fallopian tubes, bleeding/prolapse
A: GA
Hysterectomy - TAH-BSO
-position + nerve risk
-EBL
Supine
-femoral n
EBL: significant
Hysterectomy - TAH-BSO
-complications
-considerations
vasovagal (atropine)
hemorrhage
lymphadenectomy
vasc injury
ascites (RSI)
-MR is required, no movement
Pelvic Exenteration
-indications
-anesthesia
I: extensive cancer
A: GA + NGT **8-12 hr case **
Pelvic Exenteration
-complications
-considerations
dehydration (prep)
large operative fluid load
ICU intubation?
-fecal and urinary diversion needed
pain - TAP epidural
Gyn complications - Vasovagal Response
-cause
-s/s
C: dilation of cervix
S/S: brady, HoTN
Gyn complications - Vasovagal Response
-risk factors
-tx
R: cervical dilation, too light anesthesia
T: 0.5-1mg Atropine or Glyco
Gyn complications - Uterine Atony
-causes
-s/s
C: uterus cannot cx back to resting state, “boggy”
S/S: excessive bleeding, hypercontractile uterus
Gyn complications - Uterine Atony
-risk factors
-tx
R: retained placenta, long labor, chorioamnionitis, mult. pregnancies
T: fundus massage, 20 units/L Pitocin, 0.2mg Methergine IM, 250mcg Hemabate IM
Gyn Complications - Uterine Perf
-cause
-s/s
C: uterine perf
S/S: severe abd pain despite epidural
Gyn Complications - Uterine Perf
-risk factors
-tx
R: D+C
T: emergent surgery, hysterectomy or uterine repair
Gyn Complications - Hypoosmolar Fl Overload
-cause
-s/s
C: think TURP but filling of uterus with fluid for hysteroscopy
S/S: hyponatremia, pulm edema, cerebral edema , gas embolism - if air and not irrigant
Gyn Complications - Hypoosmolar Fl Overload
-risk factors
-tx
R: hysteroscopy
T: Check BMP preop, stop surgery if >500mL absorbed, limit IV fluid
Gyn Chemo Agents and complications associated:
-Doxorubicin
-Methotrexate
-Cisplatinum + Methotrexate
-Taxol + Cisplatin
Doxorubicin - cardiotoxic
Methotrexate- hepatotoxic
Cisplatinum + Methotrexate - nephrotoxic and AKI
Taxol + Cisplatin - thrombocytopenia
