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N931 Advanced Principles of Anesthesia I > Plastic Surgery > Flashcards

Plastic Surgery Flashcards

1
Q

most frequent complications of plastic surgery

A

-DVT and PE

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2
Q

other common complications of plastic surgery

A
  • postop pain
  • nausea
  • vomiting
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3
Q

most common plastic surgery procedure

A

breast augmentation

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4
Q

other common plastic surgery procedures

A
  • liposuction
  • nose reshaping
  • eyelid surgery
  • facelift
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5
Q

patient history

A
  • make sure to get a thorough patient history
  • plastic surgeon may not get quite as thorough a history so you must!!
  • consult with internist/specialist for disease states
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6
Q

preop medications for plastics

A
  • benzos (midaz esp useful for short procedures)
  • melatonin 3-10 mg preop
  • two or more agents for PONV prophylaxis
  • pre-emptive analgesia = mag, NSAIDs, gabapentinoids, ketamine
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7
Q

melatonin preop

A
  • reduce anxiety
  • decrease postop pain intensity and opioid consumption
  • improve post-op sleep quality
  • reduce post op/emergence delirium
  • may also reduce oxidative stress and anesthetic requirements
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8
Q

goals for emergence with plastics

A
  • no increase in BP/HR
  • no bucking
  • no respiratory complications
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9
Q

BIS monitor

A
  • used a lot in plastics
  • useful for patients receiving propofol-ketamine anesthesia
  • delay of 15-30 seconds from real time
  • useful in combo with EMG
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10
Q

electromyogram (EMG)

A

monitors electric activity of frontalis muscle between eyebrows
spikes suggestive of patient arousal

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11
Q

goals of GA for plastics

A
  • rapid induction
  • adequate operative conditions
  • hemodynamic stability
  • fast recovery
  • absence of side effects
  • good control of pain and emesis
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12
Q

three breast procedures

A
  • breast augmentation
  • breast reduction
  • breast lift
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13
Q

blood supply to breast

A
  • internal mammary artery for the medial aspect
  • lateral thoracic artery for lateral aspect
  • venous drainage = superficial veins under dermis and deep veins that are parallel to arteries
  • lymph drainage = retromammary lymph plexus in pectoral fascia
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14
Q

nerve supply to breast

A
  • PNS innervation of anterior and lateral cutaneous branches of 4th, 5th, and 6th intercostal nerves
  • thoracic spinal nerve, T4, innervates nipple-areola complex
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15
Q

breast augmentation

A
  • healthy vs breast cancer
  • general, cervicothoracic epidural, intercostal block, fascial plane block, tumescent injection with lidocaine
  • regional = less PONV + pain and decreased cost
  • cervicothoracic epidural (C7-T4) = better analgesia than general
  • adjunct = fascial plane block, no sympathetic blockade and better hemodynamic stability
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16
Q

breast augmentation epidural level

A

C7-T4

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17
Q

incisions in breast augmentation

A
  • infra-mammary
  • peri-areolar
  • trans-axillary
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18
Q

implant placement in breast augmentation

A
  • in pocket under mammary

- under pectoralis muscle

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19
Q

type of implant

A

silicone (800 cc max)

saline

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20
Q

post op pain in breast augmentation

A

-can extend to sternum, lateral thorax, middle back

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21
Q

anesthetic considerations for breast augmentation

A
  • position changes - head secured to table, eye protection, arms padded and wrapped to arm boards, extensions on PIV, extension on circuit
  • bra placed at end of case
  • pain management
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22
Q

complications of breast augmentation

A
  • capsular contracture (common)
  • hematoma
  • infection
  • wound dehiscence
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23
Q

breast surgery

A
  • excisional biopsy
  • breast biopsy
  • lumpectomy
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24
Q

breast biopsy anesthetic considerations

A
  • GA, regional, or local with sedation
  • supine, arm abducted, table turned
  • outpatient, minimal EBL
  • 1-1.5 hours
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25
Q

lumpectomy anesthetic considerations

A
  • wire guided (need to go to radiology before to insert wire under fluoro)
  • GA, regional, Local with sedation
  • supine
  • avoid muscle relaxants
  • <1.5 hours, outpatient
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26
Q

sentinel lymph node biopsy anesthetic considerations

A
  • for small, invasive breast cancer
  • axillary node dissection, NO RELAXATION
  • sentinel lymph node is first node to drain the afferent lymphatics from the area of the lesion
  • dye injected around breast (transient drop in pulse ox, allergic rxn)
  • gamma probe used to ID tracer in lymph nodes
  • wait for pathology (if positive nodes –> axillary dissection)
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27
Q

damage to long thoracic nerve

A
  • motor
  • radical mastectomies or with any removal of axillary lymph nodes
  • WINGED SCAPULA (scapula alata) from paralysis of serratus anterior muscle
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28
Q

damage to thoracodorsal nerve

A
  • motor

- results in palsy of the latissimus dorsi muscle

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29
Q

damage to intercostobrachial nerve

A
  • sensory

- numbness or pain in lateral aspect of axilla and medial aspect of upper arm

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30
Q

intercostobrachial neuralgia

A
  • aka post mastectomy pain syndrome

- pain in axilla, medial upper arm, and anterior chest wall

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31
Q

lymphedema

A
  • occurs when lymph vessels are not able to drain lymph fluid –> result is swelling
  • most common with axillary dissection or axillary radiation
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32
Q

types of mastectomy

A
  • modified or partial - usually chemo or radiation after
  • total or simple - breast only
  • radical - removal of breast, pectoral muscle and axillary lymph nodes
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33
Q

anesthetic considerations for mastectomy

A
  • supine
  • IV, NIBP, pulse ox on opposite arm
  • EBL 150-500 mL
  • usually admitted overnight
  • 1.5 up to 7 hours if reconstruction
34
Q

preoperative considerations for mastectomy

A
  • respiratory/airway compromise possible if radiation
  • chemo = potential for complications like cardiomyopathy
  • metastasis
  • anemia with chemo
35
Q

intraoperative considerations for mastectomy

A
  • GA (ETT/LMA) or regional
  • avoid muscle relaxants during axillary dissection so can monitor nerves
  • position changes
  • pressure dressing during emergence
  • high incidence of PONV
36
Q

breast reconstruction

A
  • immediate = use a temporary tissue expander and autologous myocutaneous flaps
  • post op chest radiation is relative contraindication
  • FLAPS
37
Q

FLAPS in breast reconstruction

A
  • deep inferior epigastric perforator
  • superficial inferior epigastric artery
  • transverse upper gracilis
  • gluteal
  • transverse rectus abdominis myocutaneous
38
Q

DIEP flap

A
  • deep inferior epigastric perforator flap
  • abdominal skin, fat and deep inferior epigastric vessels removed and replanted to create new breasts
  • internal mammary artery and vein transected suprasternal and anastomosed to epigastric vessels
  • NO VASOPRESSORS (microvascular area)
  • doppler to check vessels
  • avoid hypertension/fluid overload
  • indocyanin green may be used to check tissue perfusion
  • ICU disposition, risk of graft failure, venous congestion, fat necrosis, bleeding
39
Q

latissimus dorsi flap

A
  • transfer of back tissues (latissmis muscle, fat, blood vessels and skin) to mastectomy site
  • thoracodorsal artery supplies flap - left attached to its original supply
  • following mastectomy, patient turned lateral or prone
  • usually requires implant as well
  • overnight stay
40
Q

TRAM flap

A
  • transverse rectus abdominis myocuteanous flap (pedicle free flap type)
  • tummy tuck breast reconstruction
  • skin, fat, and muscle tunneled from abdomen to chest
  • avoid hypotension
  • doppler to check perfusion
  • flap based on superior epigastric vessels
41
Q

anesthetic considerations for breast reconstruction

A
  • vascular access (long procedure with blood loss so multiple PIVs)
  • complications r/t chemo
  • general anesthesia
  • keep warm and hydrated
  • ephedrine > phenyl for hypotension
  • heparin intraop
  • foley
  • post op pain management (regional is nice)
  • dextran for flaps (reduces clot formation in microvasc)
  • NO Nitrous (can interfere with healing)
42
Q

adriamycin

A

cardiomyopathy

43
Q

breast reduction preop eval

A
  • back pain
  • skin irritation/infection
  • skeletal deformities
  • respiratory disorders
44
Q

two techniques of breast reduction

A
  • inferior pedicle with long curved horizontal incision across crease beneath breast
  • inferior pedicle with vertical incision and short horizontal at crease (less scarring and shorter time)
  • lipo may be added
45
Q

breast reduction anesthetic considerations

A
  • GA
  • frequent position changes
  • longer procedures (3-5+ hrs)
  • fluid warmer, bair hugger, foley
  • fluid/blood volume deficits
  • PONV
  • 23 hour stay
46
Q

breast reduction complications

A
  • wound dehisence
  • infection
  • seroma
  • hematoma
  • skin flap necrosis
  • loss of sensation
  • hypertrophic scarring
47
Q

abdominal plastics surgeries

A
  • liposuction
  • abdominoplasty
  • abdominal muscle repair
  • 360 degree liposuction
  • mommy makeover
  • tummy tuck
48
Q

liposuction

A
  • second most common
  • HIGHEST morbidity and mortality
  • remove fat from unwanted areas
49
Q

preop eval for lipo

A

assess for cardiomyopathy, pulmonary disease, pulmonary embolus, thrombophilia

50
Q

dry technique of lipo

A
  • aspiration cannula inserted into space where fat will be removed
  • EBL 25-45% of aspirated volume
  • not recommended, not done as much
51
Q

wet technique of lipo

A
  • 200-300 mL of solution injected into each area to be treated
  • EBL 4-30% of volume aspirated
52
Q

superwet technique of lipo

A
  • infiltrated solution = amount of fat to be removed 1:1 ratio
  • EBL 1% of volume aspirated
53
Q

tumescent method of lipo

A
  • large amount of solution (3-4 mL per mL of expected aspirate) injected into fatty tissue
  • EBL 1% of volume aspirated
54
Q

tumescent solution

A
  • removal of SQ fat under anesthesia infiltrated with large volumes of saline solution with lido and epi
  • definition excludes use of another type of anesthetic
  • currently this one with another type of anesthesia
55
Q

klein’s solution

A
  • 50mL 1% lido (500 mg)
  • 1 mL 1:1000 epi
  • 12.5 mL 8.4% NaH2CO3
  • 1000 mL NS
56
Q

hunstad solution

A
  • 1000 mL LR
  • 50 mL 1% lido
  • 1 mL 1:1000 epi
57
Q

lido max per FDA for tumescent solution

A

35 mg/kg of total body weight

58
Q

total epi max for tumescent solution

A

50 mcg/kg

59
Q

why bicarb in tumescent solution?

A

increases pH
helps reduce pain
favors faster entry into nerve cell where the lido acts

60
Q

if tumescent solution is used, what must the anesthetist have?

A
  • monitoring
  • cardiac resuscitation
  • ventilatory support
  • recovery under anesthesia care
61
Q

why LR vs NS?

A

no burning

less sodium load

62
Q

complications of lipo

A
  • LAST
  • hypothermia
  • fat embolism/DVT/PE
  • acute anemia
  • pulmonary edema
  • fluid overload
  • electrolyte imbalance
  • death
63
Q

how much does 1:200,000 epi reduce absorption of SQ lido?

A

by 50%

64
Q

total volume of fat removed in lipo not to exceed….

A
  • <5 L

- not to exceed 5% of body weight

65
Q

high fat volumes removed in lipo associated with…

A
  • hypovolemia
  • bleeding
  • electrolyte disturbances
66
Q

IVF management with lipo

A
  • <4 L = maintenance only
  • > 4 L = maintenance + 0.25 mL/mL removed after 4L
  • goal = maintain normal intravascular volume with postanesthetic Hct > 30% and albumin > 3g
67
Q

abdominoplasty

A
  • surgery of abdominal wall
  • resection of excess skin
  • semi-fowler position (during emergence and extubation to prevent strain on suture line)
  • can be combined with lipo
  • can be combined with plication of rectus abdominis muscle
  • common in patients who have had multiple pregnancies or those who have lost a lot of weight or after bariatric procedures
68
Q

abdominoplasty anesthetic considerations

A
  • 2-5 hrs
  • post gastric bypass, ensure stable weight for at least 6 months
  • labs = CBC, CMP, EKG, liver fxn
  • O/N monitoring if comorbidities
  • GA
  • Fluid warmer, bair hugger, foley, PIV, abx
  • need to flex table for closure (semi-fowlers) to prevent strain on suture line)
  • emergence = smooth, anitemetics, binder, semi-fowlers
  • PCA +/- epidural for postop pain mgmt
69
Q

complications of abdominoplasty

A
  • ileus
  • infection
  • dehisence
  • fat embolus
  • DVT
70
Q

procedures in mommy makeover

A
  • breast augmentation
  • breast lift
  • buttock augmentation
  • lipo
  • tummy tuck
  • vaginal rejuvenation
71
Q

autologous fat grafting

A
  • transfer for fat from one or more areas to other areas in order to improve body contour
  • natural filler
  • unpredictable percentage of reabsorption
  • most frequent areas = hips, buttocks, breast, face, and hands
72
Q

3 phases of autologous fat graft

A
  • harvest adipose tissue
  • processing of lipoaspirate
  • reinjection into receptor site
73
Q

types of cosmetic facial surgery

A
  • rhytidoplasty
  • rhinoplasty
  • blepharoplasty
  • buccal fat removal
  • lip lifts
  • chin implants
  • eyebrow lift
74
Q

rhytidoplasty

A
  • face lift
  • local anesthesia (subcutaneous and nerve blocks) can be combined with conscious sedation
  • pre-anesthetic medication for sedation, anxiolysis, preventative analgesia
  • most common complication = hematoma
  • no paralysis for facial nerve monitoring
  • smooth emergence
75
Q

brow lift and blepharoplasty

A
  • brow lift = resuspection of brows; hair-line incision with flap
  • blepharoplasty = lid lift; manipulation of periorbital fat can result in retrobulbar hematoma and blindness
  • local anesthesia and IV sedation
  • possible laser use
76
Q

occulocardiac reflex

A
  • Aschner phenomenon, Aschner reflex, or Aschner–Dagnini reflex
  • a decrease in pulse rate associated with traction applied to extraocular muscles and/or compression of the eyeball
77
Q

anesthetic considerations for brow, face and lid lifts

A
  • supine, table turned away from AGM
  • LA with epi
  • abx
  • steroids
  • 1-2 hour procedure length
  • outpatient
  • occulocardiac reflex (decreased HR and BP)
  • LA with sedation so patient can open and close eyes during procedure
78
Q

rhinoplasty

A
  • surgical manipulation of nasal form for aesthetic and or functional improvement
  • find out diagnosis/indication for billing
  • septorhinoplasty includes septum repair
  • augmentation with silicon, gortex, synthetic material, cadaveric or autologous tissue (rib, cranium, iliac crest)
  • surgery may be open, closed or both
  • splint with nasal packing at end
  • outpatient
79
Q

rhinoplasty anesthetic considerations

A
  • MAC with infraorbital/nasalcillary block
  • GA (regular or oral rae ETT; OGT to remove blood in belly, nasal packing, smooth emergence)
  • table turned away from AGM
80
Q

burns surgical approaches

A
  • tangential excision - slices of eschar shaved sequentially until healthy wound bed developed; large blood loss so need epi and tourniquet
  • fascial excision - removes eschar and underlying tissues down to muscle fascia; more rapid and less blood loss than tangential; cosmetic deformities and functional loss may occur
81
Q

anesthetic considerations for burns

A
  • PRBCs in room
  • warm everything
  • room temp 82-100
  • position
  • caution with epi use
  • abx/asepsis
  • ICU
  • pain management
82
Q

rule of 9’s

A
  • used to estimate severity of burns

- 18-40% mortality (correlates with area of burn)

N931 Advanced Principles of Anesthesia I (19 decks)

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