MISC

Question 1

Describe the ideal gas for insufflation

Answer 1

Physiologically inert
Colorless
Not flammable
Undergoes pulmonary excretion

Question 2

What are the PaCO2 changes you expect with insufflation?

Answer 2

PaCO2 increases ~5-10mins post-insufflation, plateaus after 20-25mins

Question 3

What are the cardiovascular effects of pneumoperitoneum?

Answer 3

INCREASED: SVR, MAP, CVP, PAOP, left ventricular wall stress, VR (IAP<10mmHg)
DECREASED: CO (initially then increases), VR (IAP>10mmHg)
NO CHANGE: HR (may increase d/t hypercapnia or catecholamine release)

Question 4

What are the pulmonary effects of pneumoperitoneum?

Answer 4

INCREASED: peak inspiratory pressure, intrathoracic pressure, resistance, PaCO2
DECREASED: VC, FRC, compliance
Cephalad displacement of the diaphragm&raquo_space; lowers FRC & compliance, hypoxemia, endobronchial intubation

Question 5

Describe conduct of anesthesia for laparoscopy.

Answer 5

GA or RA may be used
Decompress bowel - minimize bag-mask ventilation, use NGT
Decompress bladder - empty prior to induction

Question 6

What to consider for a pediatric or a parturient?

Answer 6

pediatric - more profound CO2 absorption d/t bigger peritoneal surface area-to-body weight ratio
parturient - considered safe, if possible in the 2nd trimester and use lower insufflation pressures

Question 7

Types of pain in a post-laparoscopy patient

Answer 7

incisional pain
referred pain in the shoulder & neck - secondary to diaphragmatic irritation from CO2

Question 8

Can N2O be used instead of CO2?

Answer 8

N2O - lower incidence of peritoneal irritation and cardiac dysrhythmias BUT higher decrease in BP and more flammable vs CO2

No significant difference in bowel distention & PONV for N2O/O2 vs air/O2

No conclusive evidence against N2O use

Question 9

Describe the physiologic effects of ECT

Answer 9

After the stimulus > > parasympathetic discharge: bradycardia, PAC/PVC, asystole > > seizure > > sympathetic discharge: tachycardia, HTN

Also increases: ICP, IOP, intragastric pressure, ACTH, cortisol, epinephrine, vasopressin, prolactin, GH

Question 10

Co-morbidities during preanesthetic evaluation for ECT

Answer 10

Increased risk of complications:
- CVD
- space-occupying lesions
- unstable cardiac disease

Pheochromocytoma - should not receive ECT d/t catecholamine surge

Question 11

Is ECT safe for a parturient?

Answer 11

Yes, but avoid hyperventilation because it can decrease uteroplacental perfusion

Question 12

Is ECT safe for patients with pacemaker or ICD?

Answer 12

Yes

Question 13

Conduct of anesthesia during ECT

Answer 13

• standard monitors
• preoxygenation
• anticholinergic (to blunt the parasympathetic response)
• IV induction: methohexital, propofol, etomidate
• use oral guard/bite block
• inflate BP cuff at leg (to act as a tourniquet and visually monitor seizure activity)
• hyperventilate (to lower seizure threshold)
• muscle relaxant: succinylcholine
• continue PPV w/ 100% O2 (during the seizure)
• beta-blocker or vasodilator (to blunt sympathetic response)

*rarely are patients intubated, may be done as OPT

Question 14

Most common problem in ambulatory surgery causing a delay in discharge

Answer 14

PONV