Laproscopic Flashcards
1
Q
What are the common laparoscopic surgeries?
A
- GI
- gastric
- colonic
- splenic
- hepatic
- gallbladder
- gynecologic
- hysterectomy
- Urologic
- nephrectomy
2
Q
How does laparoscopic surgery compare with general surgery?
A
- lower pain scores and opioid requirements
- earlier ambulation and return to normal activities
- lower incidence of post-operative ileius
- usually faster recovery, shorter hospital stay (SDS)
- reduced post-op pulmonary/diaphragmatic dysfunction
- not for everyone, can still have severe post op pulmonary dysfunction leading to hypoxia
- less stress response and wound complications
- usually lower cost
3
Q
What are the relative contraindications of laparoscopic surgery?
A
- Increased ICP
- hypovolemia
- V/P shunt or peritoneojugular shunt
- ok if they have unidirectional valve resistant to IAP (intra-abdominal pressure)
- Severe CV disease
- severe respiratory disease
4
Q
How is the laparoscopic technique done?
A
- small incisions made and intraperitoneal space is insufflated with CO2
- Trochars may be inserted blindly or by using a mini laparotomy (this is safer)
- After placement is verified , abdomen is insufflated until intraabdominal pressure reaches goal (usually 15 mmHg or less)
5
Q
How can the pneumoperitoneum be insufflated?
A
- CO2
- stimulates cardiovascular system
- Inert gasses (helium and argon)
- prevent the increase in absorbed CO2
- accentuates decrease in cardiac output
- Gasless laparoscopy
- more difficult for surgeon
- relies on wall lift obtained by a fan retractor
- may be safer for cancer patients in reducing metasis
- less hemodynamically challenging for really fragile patients
- increases surgical time and cost
6
Q
Why is CO2 the gas of choice?
A
- more soluble in blood than air, helium, oxygen, or nitrous oxide
- capacity for carriage in the blood
- rapid elimination
- better outcomes compared with He embolus)
- nonflammable/noncombustible can be used with diathermy
7
Q
What changes can CO2 in the peritoneum cause?
A
- PaCO2 progressively rises to reach a plateau 15-30 minutes after insufflation
- If it continues to rise, search for a pathologic cause (embolism, emphysema, MH)
- respiratory and cardiovascular changes
8
Q
What should you consider regarding the anesthesia for a laparoscopic procedure?
A
- It can potentially be a high-risk procedure
- pneumoperitoneum + positions required = pathophysiological changes
- often long duration
- risk of unsuspected visceral injury
- difficulty in evaluating the amount of blood loss
- at risk for aspiration of gastric contents
9
Q
Why does the PaCO2 increase during laparoscopic surgery?
(9)
A
- absorption of CO2 from the peritoneal cavity (primary reason)
- abdominal distension
- VQ mismatch
- decreased FRC
- decreased pulmonary compliance
- Patient position
- VQ mismatch
- Depression of ventilation by anesthetic agents if spontaneous breathing
- CO2 emphysema- SQ or body cavities
- Capnothorax (pneumothroax with CO2)
- CO2 embolism
- Selective bronchial intubation
10
Q
What affects the absorption of CO2?
(4)
A
- Diffusibility of gas
- absorption area
- vascularity of insufflation site
- greater in pelvic surgery than in intraperitoneal surgery
11
Q
How much does insufflation decrease pulmonary compliance?
How much should you increase alveolar ventilation?
A
- pulmonary compliance decreases 30-50%
- increase alveolar ventilation 10-25%
12
Q
What are the hemodynamic changes seen in laproscopic surgeries?
(9)
A
- Decreased CO 10-30% (depends on insufflation and position)
- decreased venous return
- decreased LVEDV
- Increased intrathoracic pressure
- increased right atrial and PA occlusion pressures
- minimal increase HR
- Increased aBP, PVR, SVR
- catecholamines
- renin-angio
- vasopressin
- arterial compression by high IAP
- may increase myocardial wall tension and O2 demand
- increased risk for arrhythmias
- d/t peritoneal stretching, intolerance of hemodynamic changes, and increased CO2
13
Q
Explain the flow chart of what occurs with increased intra-abdominal pressure
A
14
Q
What are things a CRNA can do to attenuate the changes caused by increased abdominal pressure?
A
- fluid load before insufflation
- us alpha-2 agonists like clonidine, dexmedetomidine, and beta blockers
- Remifentanyl can help reduce hemodynamic response
- In pts at risk for CHF:
- remember that normalization of HD parameter does not occur for at least one hour post-op so CHF can develop in PACU
15
Q
Describe hemodynamic alterations in:
Splanchnic
kidney
head
A
- Splanchnic
- usually unchanged- mechanical compression + neuroendocrine vasoconstriction balance by hypercarbic dilation
- Kidney- decreased GFR, renal plasma flow, UOP
- Head-
- increased cerebral blood flow and ICP in steep t-burg
- increased IOP in steep t-burg
