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6901 > Laparoscopic/Robotic Surgery, Outpatient Anesthesia > Flashcards

Laparoscopic/Robotic Surgery, Outpatient Anesthesia Flashcards

1
Q

Laparoscopic surgeries vs robotic overall

A

Laparoscopic: General, gynecologic, urologic
Robotic: Can be applied to any subspecialty, use of this type is growing, GI/Cardiac/Thoracoscopic/urologic

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2
Q

Disadvantages to laparoscopy and robotics

A

Increased surgical expense

Longer operating time (until they’re proficient, takes 400 cases)

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3
Q

Advantages of laparoscopy and robotics

A 
Smaller incision
Decreased EBL
Decreased post-op pain
Decreased pulmonary morbidity
Shorter recovery/hospital stay
Less post-op ileus
Robotic prostatectomy-decreased incontinence and impotence
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4
Q

Contraindications to laparoscopy

A 
Diaphragmatic hernia
Acute/recent MI
Severe pulmonary disease
VP shunt
CHF or valve disease (Aortic stenosis, mitral valve regurg)
Hx CVA, cerebral aneurysm
Increased ICP
Glaucoma
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5
Q

Contraindications to robotic surgery

A

Poor pulmonary function test for robotic cardiac surgery - single lung ventilation may be poorly tolerated
History of stroke or cerebral aneurysm - prolonged Trendelenburg position

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6
Q

Closed technique for CO2 insufflation

A

Blind insertion of spring-loaded needle (veress needle) pierces the abdominal wall at thinnest point (sub-umbilicus)
Testing for placement:
-Aspiration/Irrigation (NS)/Aspiration (no return of NS=good placement)
-Hanging-drop test: Drop NS out of syringe onto hub of needle, drop should fall as abdominal wall is lifted
-Advancement test: If can advance 1cm deeper without resistance=good placement

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7
Q

Open technique for CO2 insufflation

A

Trocar placed under direct vision after midline vertical incision
-Avoids blind insertion like in closed technique so it’s safer but takes longer

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8
Q

CO2 insufflation

A

Creates a pneumoperitoneum
Standard to keep IAP below 15 mmHg
-Get significant physiologic changes at higher IAP

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9
Q

Why CO2 is the gas used for insufflation

A

Non combustible, more soluble in blood

  • Increased safety margin, decreased consequences of gas embolism
  • Rapidly returned from periphery and readily eliminated by the lungs
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10
Q

Cardiac arrhythmias during insufflation

A

Bradyarrhythmias, dysrhythmias, asystole
-Due to sudden stretching of the peritoneum - vagal tone
Treatment:
-Slow insufflation
-Give an anticholinergic
-If persisting/leads to HD compromise tell surgeon and release pneumoperitoneum

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11
Q

Hemodynamic effects of pneumoperitoneum

A 
Increased SVR (20%)
Increased MAP
-Due to increased sympathetic output from CO2 absorption and neuroendocrine response to pneumoperitoneum
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12
Q

What pressure should the IAP be kept to to minimize cardiovascular effects

A

12-15 mmHg

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13
Q

Why increased IAP leads to increased SVR and MAP

A

Activates the sympathetic system

  • catecholamine release
  • RAAS system
  • vasopressin release
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14
Q

IAP pressure effect on preload/intravascular volume

A

In hypovolemic patients: decreased preload because venous vessels are compressed
Increased intravascular volume when liver and spleen are compressed in steep Trendelenburg
-CO increase if IAP<15 (increased return)
-CO decrease if IAP>15 (decreased return, BP)

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15
Q

Physiologic effects of hypercapnia/respiratory acidosis

A
  • Pulmonary vasoconstriction
  • Decreased myocardial contractility
  • Increased arrhythmias
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16
Q

Insufflation effects on respiratory system

A

Decreased FRC
Decreased TLC -> atelectasis -> increased airway pressure
CO2 absorption plateaus in 10-15 minutes after initiation

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17
Q

Neuroendocrine response to pneumoperitoneum

A
  • Increased antidiuretic hormone

- Renal vasoconstriction/hypercarbia -> decreased renal blood flow

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18
Q

Local/regional anesthesia for laparoscopic surgeries

A

Shorter procedures with lower IAP (diagnostic procedure)

-Minimal head-down tilt

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19
Q

LMA anesthesia for laparoscopic surgeries

A 
Not routinely done in US, but proseal is used
Rule of 15s
-<15 minutes operating time
-15 degrees Trendelenburg
-15% above IBW
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20
Q

Anesthesia medication management for laparoscopic procedures

A

Use a short acting agent to speed recovery

  • Des or Sevo
  • Propofol TIVA
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21
Q

NMBD use for laparoscopic vs robotic surgery

A

Laparoscopic: Deep muscle paralysis isn’t necessary
Robotic: Paralysis is necessary for the entire case

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22
Q

N2O use for laparoscopic surgery

A

Controversial
Can diffuse into bowel lumen -> distension -> surgical access, increase PONV
No convincing evidence to avoid N2O unless high risk for PONV

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23
Q

Mechanical ventilation changes with laparoscopic procedures

A

Decreased lung volume and pulmonary compliance, increased PIP
-May need to increase minute ventilation 20-30%, do this by increasing the RR not TV

24
Q

Extra monitoring for laparoscopic procedures

A

Cerebral oximetry with prolonged steep head-up or head-down
Fluid minimization and goal directed administration
-With steep head-down pts are at risk for developing facial, pharyngeal, laryngeal edema and ischemic optic neuropathy
-High UOP may interfere with surgical procedure (robotic prostatectomy)

25
Q

PONV for laparoscopic procedures

A

Pts with this type of surgery are high risk for PONV

  • Decadron 4/Zofran 4
  • Hydration
  • Scop patch
26
Q

ETT complication with pneumoperitoneum

A

Endobronchial intubation (from pressure on diaphragm)

  • Decreased SaO2
  • Increased Pulmonary pressures
27
Q

Most common respiratory complication during laparoscopy

A 
Subcutaneous emphysema
Predictors:
-OR time >200 minutes
-6+ surgical ports
S/Sx: Sudden rise in ETCO2, increased pulmonary pressures
28
Q

Pneumothorax and laparoscopy

A 
Movement of gas through weak areas/defects in diaphragm
S/Sx:
-May be asymptomatic
-Increased Peak pressures
-Decreased SaO2
-Decreased BP
29
Q

Gas embolism and laparoscopy

A

Low CVP increases risk of gas embolism
-Rare but mortality rate 30%
S/Sx: Decreased ETCO2, hypoxemia

30
Q

Advantages to ambulatory surgery

A
  • Cost effective
  • Patient satisfaction/convenience
  • Shorter waiting lists
  • Great flexibility for scheduling
  • Less preop testing, less postop meds
  • Lack of dependence on availability of hospital beds
  • Great efficiency/higher volume of patients
  • Low morbidity/mortality
  • Lower risk of nosocomial infections
31
Q

Disadvantages for ambulatory surgery

A
  • Reliable transportation and assistance with postop instructions
  • Person to remain with pt for 24 hours
  • Efficiency promotes discharge -> Less time to manage complications without backing up schedule
  • Lack of resources
  • Children have less time to adapt to surgical setting
32
Q

Facility influences and considerations for ambulatory surgery

A
  • OR schedule, production pressure
  • Anesthesia aids?
  • Equipment: emergency airway, blood, lab, medications
  • Staff: availability, education, training (ACLS?)
  • Size: unanticipated extended recovery time
  • Location of facility in relation to hospital
  • 23 hour observation: desired area for higher risk procedures
33
Q

Procedure considerations for ambulatory surgery

A

Multiple planned procedures and duration >4 hours increases the risk of complications

  • Surgical complications=greatest cause of unanticipated hospital admissions
  • Blood loss, fluid shifts, N/V, Postop pain, invasive monitoring meds
  • Shouldn’t require intense postop pain management
34
Q

Liposuction ambulatory surgery

A
  • <3000 mL go home
  • 3000-5000 consider overnight stay
  • > 5000 overnight stay
35
Q

Fluid management for liposuction ambulatory surgery

A

(IV fluid + infiltrate) / aspirate

36
Q

Tumescent

A

Infiltrating NS or LR mixed with dilute amounts of epinephrine and lidocaine prior to suctioning

  • Provides hydro-dissection, improves hemostasis, and potentially provide perioperative analgesia
  • Limit lidocaine to 35mg/kg (55mg/kg is max)
37
Q

General anesthesia for ambulatory surgery

A

-With or without peripheral nerve block
PNB
-Reduces opioid requirements and side effects
Without PNB
-Local wound infiltration
-Exparel works for 72 hours (liposome injection of bupivacaine)

38
Q

Patient influences for ambulatory surgery

A
  • Social and physical support for 24 hours at home
  • Patient and family need to be able to understand instructions
  • Transportation to/from facility
  • Distance home from facility
39
Q

Medical clearance for ambulatory surgery

A

Few absolute contraindications to ambulatory surgery

-Not determined by age, BMI, or ASA

40
Q

Anesthesia clearance for ambulatory surgery

A

Schedule higher risk cases earlier in the day

  • Peds, diabetics, longer surgery, elderly
  • Morbid obesity (BMI>40) evaluated case by case
41
Q

Patients at increased risk for postop complications from ambulatory surgery

A
  • Potentially life threatening chronic illness (brittle diabetic, unstable angina, symptomatic asthma)
  • Morbid obesity with symptomatic cardiorespiratory problems
  • Multiple chronic centrally active drug therapy or active cocaine use
  • Ex-premature infant <60 weeks postconceptual age requiring general endotracheal anesthesia
  • No responsible adult at home to care for patient on evening after surgery
42
Q

Cardiac risks for ambulatory surgery

A

<4-6 weeks after MI and angina symptoms have disappeared
<4 weeks after angioplasty
<4-6 weeks after bare-metal stent, <12 months after drug eluting stent if therapy needs to be d/ced for surgery
Continue aspirin preop if possible

43
Q

Temp that increases risk for ambulatory surgery

A

> 37C

44
Q

Key questions for preop assessment for ambulatory surgery

A

1: Is there any benefit to this patient being in the hospital overnight after surgery?
2: Is there anything that needs to be done to enable this patient to be a day case

45
Q

Absolute contraindications for ambulatory surgery

A

No responsible caregiver
Delayed recovery anticipated
Severe uncorrectable CV disease

46
Q

Fever considerations for ambulatory surgery (adults and peds)

A

Adults: URI delay surgery 6 weeks
Peds: URI might delay surgery 2-4 weeks
-If they are afebrile and have a normal appetite

47
Q

H&P before surgery

A

Needs to be within 30 days

48
Q

NPO guidelines for ambulatory surgery

A 
Same as inpatient
-Clear liquids: 2 hours
-Breast milk: 4 hours
-Light meal: 6 hours
-Heavy foods: 8 hours
Being liberalized, data showing no increased risk of aspiration and less time NPO -> less PONV
49
Q

ASA status for ambulatory surgery

A

ASA III and IV depends on

  • Patients understanding/management of disease (extent/control of systemic disease)
  • Family support
  • Opinion of primary care physician
50
Q

Premedications for ambulatory surgery

A

Versed
-Given before induction decreases anxiety and postop nausea
-Repeated dosing -> slower recovery
-0.5mg/kg PO in peds allows separation from parents 15 mins after ingestion, doesn’t prolong recovery
COX-2 inhibitors aren’t any more effective than traditional NSAIDS
Tylenol-1 gram IV intraop resulted in therapeutic levels postop

51
Q

Monitors for ambulatory surgery

A

Routine except temperature, only monitor if significant changes are intended, anticipated, or suspected (surgery >30 mins)
-Continuous temp on all pediatric patients receiving general anesthesia

52
Q

Propofol/TIVA with ambulatory surgery (Benefits, Delivery)

A 
Benefits
-No airway irritation
-Rapid recovery, clear head
-Decreased PONV
Delivery
-Target controlled infusion (TCI) in other countries monitors blood levels to adjust dose, not available in US
53
Q

Inhaled anesthesia with ambulatory surgery

A

Most popular choice d/t ease of administration, controllability, and rapid emergence
Sevoflurane
-Associated with emergence delirium, esp in peds and teenagers (fentanyl, Propofol, midazolam reduce this)
Desflurane
-No differences in recovery room stay or PONV compared to sevo
N2O
-Improves quality and safety of induction, facilitates faster recovery, and reduces overall cost
-No effect on N/V unless baseline incidence is high

54
Q

LMA for ambulatory surgery

A

Associated with decreased sore throat, hoarseness, coughing, and laryngospasm compared to ETT

55
Q

ProSeal LMA seal pressure

A

Up to 30 cm H20

  • Increased seal pressure, reduced gastric inflation, provides gastric drainage
  • It’s use for laparoscopic surgeries remains controversial
56
Q

Discharge criteria for ambulatory surgery

A 
A/O time and place
VSS
Pain controlled with PO meds
N/V mild
No unexpected bleeding
Walk without dizziness
Discharge instructions and prescriptions
Accepts readiness for discharge
Adult to accompany home
*Not going to be "normal", return of psychomotor skills takes 24-48 hours
*Voiding isn't essential 
*No major decisions or driving for 24 hours
57
Q

Emergency medications required to be available at ambulatory surgery centers

A

Dantrolene (if triggering agents are used)
IV lipids 20% if LA is used
Surgeons should have admitting privilages at a nearby hospital

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