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NA 1 > Lap + GYN + Robots - Exam 6 > Flashcards

Lap + GYN + Robots - Exam 6 Flashcards

1
Q

Most complications from lap procedures occur during which two phases of the surgery?

A

-initial entry into abdomen
-creation of pneumoperitoneum

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2
Q

Leading cause of morbidity and mortality in lap cases:

A

severe vascular injury

followed by injury to bowel (usually with umbilical trocar

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3
Q

Lap cases can be done with an _ or _ or _ _ - _ entry technique

A

open (Hasson)
closed
left upper-quadrant (Palmar point)

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4
Q

Pts at risk for injury from umbilical entry-related lap injuries include:

A

-thin
-obese
-those with abdominal adhesions

-should have open (Hasson) or LUQ (palmar point) entry techniques instead

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5
Q

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

A

spring-loaded
infraumbilical or intraumbilical

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6
Q

An intraabdominal pressure of _ mmHg or less indicated a properly placed Veress needle

A

10

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7
Q

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.

A

false, CO2, not CO

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8
Q

Purpose of trocar in lap cases:

A

helps surgeon pass instruments into abdomen

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9
Q

T/F Trocars are inserted blindly or under direct vision after insufflation during lap cases.

A

true

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10
Q

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

A

true

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11
Q

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

A

1 - 2.5mm
vertical
lower
subcut tissue

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12
Q

Goal of open entry technique for laps:

A

-minimize risk of damage to bowel and vasc

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13
Q

CO2 is the perfect insufflating gas because:

A

-colorless
-doesn’t explode
-cheap
-easily removed by body
-nontoxic
-minimal risk of air embolism

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14
Q

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 _

A

peritoneal stretch
vagally
16mmHg
Glyco or Atropine

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15
Q

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 _

A

MAP, SVR, and HR
intrabdominal vessels
renin or vasopressin

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16
Q

_ and _ increase regardless of whether insufflation pressures are 12-20mmHg

A

MAP and SVR

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17
Q

Pneumoperitoneum hemodynamic changes
5mmHg

A

HR: inc
MAP:inc
SVR: inc
venous return: -/dec
CO: -/dec

-no sig effects on renal or resp. system

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18
Q

Pneumoperitoneum hemodynamic changes
10mmHg - CV changes

A

HR: inc
MAP: inc
SVR: inc
venous return: -
CO: -/inc

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19
Q

Pneumoperitoneum hemodynamic changes
10mmHg - Renal + Resp

A

GFR: dec
UO: dec

EtCO2: -/inc
PCO2: inc
Art. pH: -/dec

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20
Q

Pneumoperitoneum hemodynamic changes
20mmHg - CV changes

A

HR: -
MAP: inc
SVR: inc
venous return: -
CO: -/dec

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21
Q

Pneumoperitoneum hemodynamic changes
20mmHg - renal + resp changes

A

GFR: dec a lot
UO: dec a lot

EtCO2: -/ inc
PCO2: inc
Art pH: dec

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22
Q

Pneumoperitoneum hemodynamic changes
40mmHg - CV changes

A

HR: dec
MAP: inc
SVR: inc
venous return: dec
CO: dec

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23
Q

Pneumoperitoneum hemodynamic changes
40mmHg - renal and resp changes

A

GFR: dec a lot
UO: dec a lot

EtCO2: inc
PCO2: inc
Art pH: dec

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24
Q

Which has larger effect on central pressures, insufflation or position changes for lap?

A

position changes (steep trend)

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25
Q

Steep trend causes a large increase in CVP because it eases _ _ and increases _ pressure at the level of the _ _ _

A

venous return
hydrostatic
external auditory meatus

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26
Q

T/F Reverse trend increases preload, which raises CO

A

false, decreases both

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27
Q

Why does SV decrease during a pneumopeitoneum?

A

decreased venous return

-NOT depressed myocardial function

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28
Q

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

A

SVR
depressant

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29
Q

Variable impact on CO/ CI from a pneumoperitoneum is dependent on multiple factors such as:

A

-volume status
-use of PPV
-insufflation pressures
-ability of pt’s HR to increase to compensate changes

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30
Q

Pneumoperitoneum can cause significant _ in LVEDP which can _ cardiac function if not accompanied by sufficient _ in HR

A

decrease
decrease
increase

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31
Q

Pneumoperitoneum can increase _ _ (QTd), which _ risk of arrhythmias and cardiac effects

A

QT dispersion (reflects ventricular instability)
increase

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32
Q

Reverse trend position does what to CO?

A

decreases, less venous return

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33
Q

Cumulative effects of CO2 in pneumoperitoneum and reverse trend position can cause moderate _ in CO, significant _ in filling pressures and afterload in sick pts.

A

decrease
increase

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34
Q

Elderly pts receiving pneumoperitoneum have greater _ in CVP and _ in MAP compared to younger pts

A

increases
decreases

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35
Q

Increased abdominal pressure shifts the _ expiratory position of the diaphragm _ which decreases _, _, and _, which cause atelectasis and make ventilation difficult.

A

end
cephalad
FRC, FEV-1, and FVC

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36
Q

When MV is fixed, pneumoperitoneum is associated with increases in _ and _ with or without accompanying acidosis. This can cause pulmonary _ and cardiac _.

A

PaCO2 and EtCO2
vasoconstriction dysrhythmias

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37
Q

What increases PaCO2 during pneumoperitoneum?

A

CO2 absorption thru peritoneal serosa from increased intrabdominal pressure

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38
Q

Is increased PaCO2 with acidosis from insufflation metabolic or respiratory?

A

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

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39
Q

Max absorption of CO2 is noted with intrabdominal pressure of _ torr/mmHg

A

10mmHg

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40
Q

PaCO2 levels plateau approx. _ mins after insufflation.

A

40 min

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41
Q

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.

A

False,
extraperitoneal insufflation/ subcut absorption

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42
Q

T/F It is possible for a pt to experience orbital emphysema and pneumopericardium after extraperitoneal absorption of CO2.

A

true :(

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43
Q

Subcutaneous emphysema from extraperitoneal insufflation
-risk factors (5 big ones)

A

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

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44
Q

Red flag signs of subcut emphysema:

A

-crepitus
-hypercarbia
-increased EtCO2
-decreased lung compliance
-arrhythmias
-HTN

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45
Q

How to manage subcut emphysema:

A

-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

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46
Q

Which region of lungs can experience atelectasis during insufflation?

A

dependent

-perfusion to the nonventilated alveoli cause a shunt with impaired oxygenation and CO2 elimination, increasing arterial-EtCO2 difference

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47
Q

Increased intraabdominal pressure decreases pulmonary compliance in supine pts by ~ _ %

A

43%

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48
Q

Increased V/Q mismatching and changes in oxygenation during lap cases are most likely more dependent on which factors, effects of anesthetics or pneumoperitoneum?

A

anesthetic effects BC ** they attenuate or inhibit hypoxic pulmonary vasoconstriction (HPV) reflex ** which offsets VQ mismatch from pneumoperitoneum

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49
Q

Pulmonary function changes associated with pneumoperitoneum:

A

INCREASES:
PIP
Intrathoracic Pressure

DECREASES:
VC
FRC
Pulm compliance

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50
Q

Anesthesia + pneumoperitoneum have an additive effect on reducing _ and _ _

A

FRC and pulm compliance

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51
Q

Pulm compliance drops by _ % and peak plateau pressure increases by _ % in steep trend position with pneumoperitoneum

A

pulm compliance dec 50%
peak plateau inc 50%

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52
Q

Which position counteracts effects of pneumoperitoneum and improves diaphragmic function?

A

reverse trend

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53
Q

Endobronchial intubation can occur with pneumoperitoneum by _ the distance of the tip of the EET to the _

A

shortening
carina

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54
Q

Cephalad displacement of the diaphragm compresses the lungs and moves the position of the carina _, moving the ETT _ (cephalad/caudad)

A

up
caudad

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55
Q

Tube displacement occurs within _ mins of pneumoperitoneum creation. What can be done to check for displacement?

A

10 mins
listen to BS (reconfirm placement)

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56
Q

In the trend position, a _ - _ % increase in MV is needed to maintain pneumoperitoneum and prevent acidosis

A

20-30%

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57
Q

Which is better during a pneumoperitoneum in the trend position to control art pH, PCV or VCV?

A

PCV
-easier to ventilate, generating less max peak pressures and increased mean airway pressures
-watch Vt when pneumo pressure is released!!!

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58
Q

Lung protection strategies:

A

6-8ml/kg IBW MV
plateau pressures below 16cmH20
lowest driving pressure possible
moderate PEEP
recruitment maneuvers Q 30 min

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59
Q

Why is EtCO2 for a COPD pt in trend position with pneumoperitoneum not accurate?

A

large arterial- EtCO2 gradient is compounded by those 3 factors
-measure directly via PaCO2 via ABG or PtCO2 (noninvasive)

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60
Q

After lap cases, a slight _ respiratory pattern occurs due to which 3 factors?

A

restrictive
-pain
-diaphragmic dysfunction
-residual effects of anesthetic

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61
Q

If lap case is long, CO2 can be absorbed into _ and _ _. This allows it to be excreted back into pt for hours after.

A

bone and skeletal musc

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62
Q

Which physiologic conditions are at greatest risk for decompensation due to physiologic changes of laparoscopy?

A

increased metabolic rate (sepsis)
COPD
large vent dead space
decreased CO

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63
Q

Renal effects from pneumoperitoneum:

A

-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

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64
Q

Hepatic effects from pneumoperitoneum:

A

-ischemia 2/2 production of O2 free radicals
-bacterial translocation
-increased lipid and protein oxidative substances -> damage splanchnic tissue
-elevated liver enzymes

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65
Q

Immune effects from pneumoperitoneum:

A

-alters conc of certain cytokines within the peritoneum (decreases local immune response)= possible to cause cancer

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66
Q

Entry-related injuries for lap cases include:

A

-intestinal, vascular, and urinary tract injuries
-CO2 embolism

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67
Q

What factors increase laparoscopic injury risk? (7)

A
  1. Body habitus
  2. Anatomic anomaly
  3. Prior surgery
  4. Surgical skill
  5. Degree of abd elevation
  6. patient position
  7. Volume of gas
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68
Q

Vascular injury during lap s/s (3)

A
  1. Aspiration of blood through Veress needle
  2. Free intraperitoneal blood
  3. Unexplained hypotension and tachycardia
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69
Q

What must happen to successfully treat laparoscopic vascular injury? (not anesthesia/med related)

A

Conversion to open lap

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70
Q

Visceral injuries in lap cases are hard to recognize and may go on to cause _, _, _ _ , and MODS in untreated pts.

A

sepsis
peritonitis
resp distress

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71
Q

How can you test for urinary tract damage?

A

Injection of methylene blue dye via catheter

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72
Q

What is the best pressure for the trocar placement?

A

25mmHg

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73
Q

What is the actual incidence of gas embolism during lap surgery?

A

65-100%

74
Q

Why is CO2 used instead of helium?

A

high incidence of subcutaneous emphysema and life-threatening gas embolism with helium

75
Q

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

A

below
veress needle
trocar

76
Q

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

A
  1. right, pulmonay
  2. outflow, PAP, RV, venous return
  3. preload, CO
77
Q

S/s gas embolism

A

-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

78
Q

Best technique for dx gas embolism:

A

TEE

79
Q

Treatment of gas embolism

A

-Deflate abd, halt N2O
-Flood sterile saline on field
-Durant maneuver (position pt in L lat decub.)
-Aspirate embolism through CVP
-Support BP

80
Q

T/F Low SVR increased risk of venous gas embolism

A

false, low CVP does
-adequate hydration is important

81
Q

What can gas migration from the abdomen during lap cause?

A

Pneumothorax (UL or BL)
Pneumomediastinum
Pneumopericardium

82
Q

What kind of lap case would most likely cause gas to enter the thoracic cavity?

A

lap esophageal cases

83
Q

Pneumothorax can happen during lap cases from _ 2/2 _ airway pressures and _ pulm compliance from insufflation.

A

barotrauma
increased
decreased

84
Q

T/F Pneumothorax from CO2 insufflation is always an emergency and requires placement of a chest tube

A

false
-usually resolves quickly without intervention

85
Q

T/F Pneumothorax from barotrauma causing ruptured bleb usually resolves spontaneously without intervention

A

false,
EMERGENT, needs surgical decompression and chest tube!!!

86
Q

Factors that are predictive of pneumothorax include:

A

-max EtCO2 >50
-operative time >200 min or 3.5 hr
-use of 5+ entry points
-lap mobilization of esophagus
-operator inexperience

87
Q

Is subq emphysema risk worse with direct, indirect approach or same?

A

same

88
Q

What is concerning about severe subq emphysema of head?

A

possibility of severe airway swelling, inability to reintubate if extubated too early

pt may need to be left intubated

89
Q

Risks with other gases for insufflation:

A

O2- combustion
N2O- combustion
Air- combustion
Helium-insoluble, possibility of large gas embolism

90
Q

Cons to using CO2 as insufflation gas:

A

-resp acidosis + hypercarbia
-peritoneal and diaphragmic irritant= known to cause postop shoulder pain

91
Q

Cons of regional anesthesia over general for lap

A

Post-op shoulder pain (poorly managed with regional)
Patient discomfort
More hypotension (sympathetic blockade)

92
Q

Anesthesia-specific adverse event of laparoscopy? (postop, there is an increased incidence)

A

PONV

93
Q

Which produces less PONV: TIVA or inhaled anesthetics?

A

TIVA

94
Q

3 Major categories of pain postop lap? Majority of pain from?

A
  1. Incisional pain (parietal)
  2. Deep intraabdominal pain (visceral)
  3. Shoulder pain (referred visceral pain)
    -Majority pain from visceral on DOS
    -shoulder pain on postop day 1
95
Q

The peritoneum and viscera convey unpleasant sensations and _ reactions to injury via the _ nerve, causing painful and nonpainful sensations.

A

autonomic
vagus

96
Q

Intraabdominal CO2 contributes to postop pain by decreasing intraperitoneal _ and causing irritation of the _ nerve

A

pH
phrenic

97
Q

Methods that reduce shoulder tip pain (STP) for postop lap cases:

A

-recruitment maneuvers
-extended assisted ventilation
-active aspiration of intraabdominal gas
(most significant factor=technique of releasing pneumoperitoneum)

98
Q

Classification of robotics systems?

A

Assist(AESOP) and telemanipulators (daVinci and Senhance)
-Based on how much “hands-on” control is required

99
Q

Da Vinci system components?

A

Vision system, surgeon console, patient-side cart

100
Q

How many degrees of freedom does the EndoWrist have?

A

7
-3 arm motions (in-ou, up-down, side-side)
-3 wrist movements (side-side,left, right yaw)
-pitch
-rotation

101
Q

Where must the surgeon’s head be in order for the system to function?

A

in the viewer

-2nd surgeon must be present to ensure proper protocols and adjust camera

102
Q

Anesthetic plan for robot cases must consider these 7 factors:

A

-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

103
Q

What spatial restriction is of particular concern in robot cases? Other concerns?

A

-Inability to reach patient during emergencies
-inability to reposition emergently
-Padding between instruments and robot

104
Q

Factors beyond anesthesia’s control that prolong surgical time with robot cases:

A

-operator inexperience
-surg complexity
-time required for positioning/docking

105
Q

Which has a shorter robot undocking time, daVinci or Senhnce?

A

Senhance

106
Q

Minimum preparation (patient) for robotic surgery?

A
  1. 2 Large bore IVs
  2. Arterial line if rapid blood loss or serial labs are expected
  3. T/S for at least 4 units of blood
  4. Invasive monitoring
  5. Emergent undocking protocol
  6. 2 blood pressure cuffs/2 pulseox
107
Q

What position is most commonly used for robotic procedures?

A

Steep trendelenburg
-Head down 40-45 degrees
-must document checking pt position Q15 or when robot/ OR table is moved

108
Q

Changes associated with Steep Trend position
-CV

A

INCREASED:
-MAP
-CVP
-PAWP
-SVR/afterload

NO CHANGE:
-HR
-SV
-MVO2

109
Q

Changes associated with Steep Trend position
-Resp

A

INCREASED:
-airway resistance
-peak airway pressure
-plateau pressure
-EtCO2
-upper airway edema

DECREASED:
-compliance
-VC
-FEV1

110
Q

Physiologic changes with steep trend
-Neuro

A

INCREASE:
-ICP
-Hydrostatic pressure gradient
-IOP
-Cerebrovascular resistance

DECREASE:
-Cerebral venous drainage

UNCHANGED:
-Regional cerebral oxygenation
-Cerebral perfusion pressure

111
Q

When to recheck BS with robot cases/lap cases?

A

-after insufflation
-after repositioning/steep trend

112
Q

Overall effects of increased filling pressure and SVR during steep trend=

A

prolonged isovolumetric relaxation time

113
Q

Which part of lungs experience atelectasis during pneumoperitoneum and steep trend?

A

dorsal part of lungs

114
Q

Which vent setting makes a big difference in improving compliance, oxygenation, and homogenous ventilation ability?

A

PEEP 15cm H2O

115
Q

Respiratory changes due to steep trendelenburg are raised in which patient disease group?

A

COPD

116
Q

How long can lung atelectasis due to reductions in FEV1 and vital capacity continue on for in COPD patients?

A

5 days

117
Q

What are most of the prolonged changes to respiratory physiology r/t steep trendelenburg caused by?

A

airway edema
-can last up to 2 hr postop

118
Q

ICP raises more than _ mmHg in the steep trend position.

A

20mmHg
-this is due to increases in MAP and decreased venous drainage

119
Q

The ICP changes due to Steep Trens positioning are directly related to which other vital sign?

A

MAP increase

120
Q

Major causes of POVL (disease)?

A

AION - anterior ischemic optic neuropathy
PION - posterior ischemic optic neuropathy
CRAO - central retinal artery occlusion
Cortical blindness

121
Q

Risk factors for AION
Risk factors for PION

A

AION:
-Cardiac, major vascular, spine
PION:
-Prone, steep trendelenburg, high venous pressures

122
Q

S/S AION and PION:

A

sudden onset of painless vision loss and visual field deficits, seen on emergence of anesthesia

123
Q

What causes CRAO and cortical blindness?

A

Procedures with high embolic load
Severe hypotension
Direct global compression

124
Q

Independent risk factors for POVL?

A

-Male gender
-Obesity
-Prolonged anesthetic duration
-Prone
-Greater EBL
-HoTN
-Lower percentage of colloid replacement

125
Q

What two mechanisms increase risk for POVL for robotic surgery?

A

Increased venous congestion and interstitial edema

126
Q

Prevention of POVL:

A

-minimize surgical time
-staged procedures if possible
-minimize EBL
-decrease venous congestion
-HOB at or above level of heart
-colloids
discuss risks w pt

127
Q

Which medications might help reduce IOP and reduce risk of POVL in steep trend?

A

-topical beta blockers
-carbonic anhydrase inhibitors (dorzolamide-timolol)

128
Q

ERAS preoperative guidelines, overall goal

A

prevent catabolic state associated with fasting/dehydration

129
Q

ERAS intra/postoperative guidelines (overall goal)

A

maintain euvolemic state
fast track pt into early ambulation/feeding

130
Q

Mechanism by which ERAS improves patient outcomes?

A

Stress reduction
-Faster return of GI fx

131
Q

Perioperative fluid overload, effects postoperatively

A
  1. Increase morbidity
  2. Postop ileus
    -Hypoproteinemia -> delayed gastric emptying
132
Q

What is the carbohydrate drink for ERAS

A

12.5% maltodextrin 100g night before, then 50g 2-3hr before induction
-gatorade

133
Q

What are the effects of overnight fasting (physiologic)?

A

Inhibits insulin secretion:
-Insulin resistance

Promotes release of cortisol and glucagon:
-Glycogen depletion
-Protein breakdown

134
Q

Infusion rate of isotonic crystalloid rate for intraoperative period ERAS?

A

3 +/- 2 mL/kg

135
Q

Should you continue IV fluids in PACU?

A

no, DC unless otherwise indicated

136
Q

PONV treatment based on # of nausea risk factors

A

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)

137
Q

D+C
-indications
-anesthesia

A

I: uterine bleed, dysmenorrhea, infertility

A: LA, SAB = T10, GA

138
Q

D+C
-position + nerve risk
-EBL

A

Dorsal lithotomy with allan stirrups
-CPN, obturator, saphenous, femoral n = foot drop

blood: significant

139
Q

D+C
-complications
-considerations

A

vasovagal (atropine), uterine atony, uterine perf

-keep deep during dilation
-preop H+H and HCG
-RSI-ETT>1

140
Q

Suction Curettage
-indications
-anesthesia

A

I: pregnancy termination <12 wks

A: none :’( medical termination

141
Q

Suction Curettage
-position + nerve risk
-EBL

A

Dorsal Lithotomy with allan stirrups
-CPN, obturator, saphenous, femoral n = foot drop

blood: 10-400mL

142
Q

Suction Curettage
-complications
-considerations

A

incomplete abortion
sepsis (retained placenta)

-seizure during LA injection
-infection/fever
-be nice, this is a sensitive time

143
Q

D+E
-indications
-anesthesia

A

I: pregnancy termination >16 wk

A: GA

144
Q

D+E
-position + nerve risk
-EBL

A

Dorsal Lithotomy + allan stirrups
-CPN, obturator, saphenous, femoral n = foot drop

blood: 300-500mL

145
Q

D+E
-complications
-considerations

A

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

146
Q

Ectopic Pregnancy Surgery
-indications
-anesthesia

A

I: fallopian tubes usually, pain, bleeding positive HCG

A: medical, methotrexate; surgical GA bc this is awful emotionally

147
Q

Ectopic Pregnancy Surgery
-position + nerve risks
-EBL

A

EBL: significant (rupture)

148
Q

Ectopic Pregnancy surgery
-complications
-considerations

A

hemorrhage
severe postop pain

-transvaginal US and IVF prior to induction
-be nice, this is a sensitive time

149
Q

Cervical Cerclage
-indication
-anesthesia

A

I: cervical incompetence ~14-18wks

A: SAV (T10) and therapeutic commmunication

150
Q

Cervical Cerclage
-position + nerve risk
-EBL

A

Lithotomy LEFT LATERAL pelvic
Trend
-CPN injury

blood: minimal

151
Q

Cervical Cerclage
-complications
-considerations

A

cervical rupture
chorioamnionitis
preterm labor
spont abortion

-tocolysis - indomethacin
-IVF before SAB
-RSI if >16wks
-extubate awake

152
Q

Staging Lap
-indication
-anesthesia

A

I: Cancer ( open explore or debulk and confirm)

A: LA + MAC or GASta

153
Q

Staging Lap
-position + nerve risk
-EBL

A

EBL: significant

154
Q

Staging Lap
-complication
-considerations

A

hemorrhage
lymphadenectomy
vasc injury
ascites (RSI)
chemo effects

-expect fluid shifts (ascites/peritoneal)
-endocrine diseases too?
-stress steroid?

155
Q

Ex Lap
-Indication
-anesthesia

A

I: diagnostic

A: GA +ETT

156
Q

Ex Lap
-position + nerve risk
-EBL

A

open-supine
lap-dorsal
lithotomy
-

EBL: significant
open>lap

157
Q

Ex Lap
-complications
-considerations

A

hemorrhage
thrombophlebitis

pneumoperitoneum

158
Q

Hysteroscopy
-indication
-anesthesia

A

I: abnormal uterine bleeding, biopsy, IUD

A: LA + MAC (symptoms ) or GA

159
Q

Hysteroscopy
-position + nerve risk
-EBL

A

EBL: minimal

160
Q

Hysteroscopy
-complications
-considerations

A

TURP LIKE SYNDROME (pulm edema, cerebral edema)
vasovagal (atropine)
gas embolism

-check BMP preop
-stop >500mL fluid
-LA pericervical
-toradol for pain

161
Q

Hysterectomy - Vaginal
-indication
-anesthesia

A

I: uterus removal, preferred method

A: LA + MAC, RA (SAB ~ T5) or GA

162
Q

Hysterectomy - Vaginal
-position + nerve risks
-EBL

A

Doral Lithotomy
-femoral n

EBL: minimal

163
Q

Hysterectomy - Vaginal
-complications
-consideration

A

vasovagal (atropine)
hemorrhage
lymphadenectomy
vasc injury
ascites (RSI)

-

164
Q

Hysterectomy - Abdominal (Lap/Robot)
-indications
-anesthesia

A

I: large uterus, bony pelvis, adhesions, cancer

A: GA + ETT + NGT

165
Q

Hysterectomy - Abdominal (Lap/Robot)
-position + nerve risk
-EBL

A

Steep Trend
-fem nerve

EBL: minimal

166
Q

Hysterectomy - Abdominal (Lap/Robot)
-complications
-considerations

A

vasovagal (atropine)
hemorrhage
lymphadenectomy
vasc injury
ascites (RSI)

-MR is required, no movement

167
Q

Hysterectomy - TAH-BSO
-indications
-anesthesia

A

I: uterus, cervix, fallopian tubes, bleeding/prolapse

A: GA

168
Q

Hysterectomy - TAH-BSO
-position + nerve risk
-EBL

A

Supine
-femoral n

EBL: significant

169
Q

Hysterectomy - TAH-BSO
-complications
-considerations

A

vasovagal (atropine)
hemorrhage
lymphadenectomy
vasc injury
ascites (RSI)

-MR is required, no movement

170
Q

Pelvic Exenteration
-indications
-anesthesia

A

I: extensive cancer

A: GA + NGT **8-12 hr case **

171
Q

Pelvic Exenteration
-complications
-considerations

A

dehydration (prep)
large operative fluid load
ICU intubation?

-fecal and urinary diversion needed
pain - TAP epidural

172
Q

Gyn complications - Vasovagal Response
-cause
-s/s

A

C: dilation of cervix

S/S: brady, HoTN

173
Q

Gyn complications - Vasovagal Response
-risk factors
-tx

A

R: cervical dilation, too light anesthesia

T: 0.5-1mg Atropine or Glyco

174
Q

Gyn complications - Uterine Atony
-causes
-s/s

A

C: uterus cannot cx back to resting state, “boggy”

S/S: excessive bleeding, hypercontractile uterus

175
Q

Gyn complications - Uterine Atony
-risk factors
-tx

A

R: retained placenta, long labor, chorioamnionitis, mult. pregnancies

T: fundus massage, 20 units/L Pitocin, 0.2mg Methergine IM, 250mcg Hemabate IM

176
Q

Gyn Complications - Uterine Perf
-cause
-s/s

A

C: uterine perf

S/S: severe abd pain despite epidural

177
Q

Gyn Complications - Uterine Perf
-risk factors
-tx

A

R: D+C

T: emergent surgery, hysterectomy or uterine repair

178
Q

Gyn Complications - Hypoosmolar Fl Overload
-cause
-s/s

A

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

179
Q

Gyn Complications - Hypoosmolar Fl Overload
-risk factors
-tx

A

R: hysteroscopy

T: Check BMP preop, stop surgery if >500mL absorbed, limit IV fluid

180
Q

Gyn Chemo Agents and complications associated:
-Doxorubicin
-Methotrexate
-Cisplatinum + Methotrexate
-Taxol + Cisplatin

A

Doxorubicin - cardiotoxic
Methotrexate- hepatotoxic
Cisplatinum + Methotrexate - nephrotoxic and AKI
Taxol + Cisplatin - thrombocytopenia

NA 1 (31 decks)

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