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AS - N931 Advanced Principles of Anesthesia > Plastics > Flashcards

Plastics Flashcards

1
Q

Most common plastic surgery complications are _____ & _____

A

DVT & PE

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2
Q

Other common plastic surgery complications include:

A

Postop pain, nausea, & vomiting

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3
Q

Plastic Surgery

Anesthetic Considerations

A

1° patient safety
DVT/PE prophylaxis
Liposuction guidelines on Lidocaine/Epi doses
Adequate hydration

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4
Q

Most common plastic surgery procedure

A

Breast augmentation

Followed by liposuction, rhinoplasty, blepharoplasty, rhytidectomy (face lift)

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5
Q

Preanesthesia Evaluation

A

CBC, BMP, coags, HFP, HIV, Hep B/C, HCG
Assess current medications - NSAIDs, vitamin E, contraceptives, weight loss, illegal drug use, prescriptions
Thyroid hormones, antidepressants, vitamins/minerals, herbals
Potential anticoagulant, antiplatelet, procoagulant effects, & effect on anesthetics

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6
Q

What supplements have anticoagulant effects?

A 
Alfalfa
Dong quai
Anise
Saffron
Bromelain
Castanea sativa
Ginseng
Arnica
Kelp
Horseradish
Red clover
Asiatic ginseng
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7
Q

What supplements have antiplatelet effects?

A 
Fish oil
Garlic
Dong quai
Celery
Onion
Clove
Chili pepper
Gingko biloba
Black cohosh
Licorice root
Turmeric
Vitamin E
Asiatic ginseng
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8
Q

Alternative preop medication to reduce anxiety

A 
Melatonin 3-10mg
↓postop pain
↓opioid consumption
Improve postop sleep quality 
↓postop/emergence delirium 
↓oxidative stress & anesthetic requirements
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9
Q

Regional Anesthesia

Advantages

A

Fewer complications
Safer recovery
Improved postop analgesia

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10
Q

BIS

A

Delay 15-30 seconds

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11
Q

General Anesthesia

A

Risks include difficult or failed intubation, kinked/occluded ETT, dental damage, anesthesia gas machine errors, malignant hyperthermia
LMA frequently utilized
Room air general d/t airway fire risk

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12
Q

Breast Blood Supply

A

Medial aspect = internal mammary artery
Lateral aspect = lateral thoracic artery
Venous drainage = superficial veins under dermis & deep veins parallel the arteries
Lymph drainage = retromammary lymph plexus in the pectoral fascia

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13
Q

Breast Nerve Supply

A

Peripheral nervous system anterior & lateral cutaneous branches innervation 4th, 5th, & 6th intercostal nerves
Thoracic spinal nerve T4 innervates nipple-areola complex

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14
Q

Breast Augmentation

Anesthetic Considerations

A

Healthy vs. breast cancer
General or regional
Cervicothoracic epidural or intercostal/fascial plane block
Position changes - secure head & arms to bed, eye protection, PIV extension tubing
Bra/binder place at end

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15
Q

Cervicothoracic Epidural

A

C7-T4

Analgesia > general

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16
Q

Fascial Plane Blocks

A

Adjunct block
No sympathetic blockade
Hemodynamic stability

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17
Q

Breast Augmentation Incisions

A
  1. Infra-mammary
  2. Peri-areolar
  3. Trans-axillary
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18
Q

Implants

A

Silicone or saline

Place in pocket under mammary gland or pectoralis muscle

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19
Q

Breast Augmentation

Complications

A

Capsular contracture
Hematoma
Infection
Wound dehiscence

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20
Q

Breast Surgery Lumpectomy

A

Wire-guided (radiology wire inserted under fluoroscopy)
Avoid muscle relaxants
< 1.5hrs
Outpatient procedure

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21
Q

Sentinel Lymph Node Biopsy

A 
Small, invasive breast cancer
Axillary node dissection - NO relaxation
Sentinel lymph node = 1st node to drain afferent lymphatics from lesion area
Dye injected around breast
Transient ↓SpO2 
Pathology + nodes → axillary dissection
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22
Q

Long Thoracic Nerve Damage

A

Motor
Winged scapula (scapula alata) d/t serratus anterior muscle paralysis
Complication from radical mastectomy or w/ axillary lymph node removal

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23
Q

Thoracodorsal Nerve Damage

A

Motor

Results in latissimus dorsi muscle palsy

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24
Q

Intercostobrachial Nerve Damage

A

Sensory

Numbness or pain in axilla lateral aspect & medial aspect upper arm

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25
Q

Intercostobrachial Neuralgia

A

Post-mastectomy pain syndrome
Numbness
Axilla, medial upper arm,& anterior chest wall pain

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26
Q

Lymphedema

A

Most common w/ axillary dissection & radiation

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27
Q

Mastectomy

A

Modified or partial - postop radiation/chemo
Total or simple - removes breast only
Radial - removes breast, pectoral muscle, & axillary lymph nodes

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28
Q

Mastectomy

Anesthetic Considerations

A 
Supine
Pox, PIV, & NIBP on opposite arm or LE
EBL 150-500mL
Admit overnight
1.5hrs
Reconstruction up to 7hrs
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29
Q

Avoid what medications during axillary dissection?

A

Muscle relaxants

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30
Q

Chemotherapy Complications

A 
Cardiomyopathy
Anemia
Pulmonary fibrosis
Interstitial infiltrates
Pleural effusion
Myelosuppression
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31
Q

Radiation Complications

A

Respiratory or airway compromise possible

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32
Q

Breast Reconstruction

A

Immediate - temporary tissue expander or autologous myocutaneous flaps
Flaps = DIEP/SIEA/TUG/TRAM

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33
Q

Breast reconstruction relative contraindication:

A

Postop chest radiation

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34
Q

DIEP Flap

A

Deep inferior epigastric perforator flap
Abdominal skin, fat, & deep inferior epigastric vessels are removed & replanted to create new breasts
Internal mammary artery & vein are transected suprasternal & anastomosed to epigastric vessels
NO VASOPRESSORS
Avoid HTN or fluid overload
Indocyanine green to check tissue perfusion
ICU dispo, graft failure risk, venous congestion, fat necrosis, bleeding

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35
Q

Latissimus Dorsi Flap

A

Transfer back tissues (latissimus muscle, fat, blood vessels, & skin) to the mastectomy site
Thoracodorsal artery supplies the flap - left attached to its original supply
Turn patient lateral or prone
Overnight hospital admission
AVOID PHENYLEPHRINE

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36
Q

TRAM Flap

A

Transverse rectus abdominis myocutaneous - pedicle or free flap
Tummy tuck breast reconstruction
Skin, fat, & muscle tunneled from abdomen to chest
Avoid hypotension
Doppler to check perfusion
Flap based on superior epigastric vessels
AVOID PHENYLEPHRINE

37
Q

Breast Reconstruction

Anesthetic Considerations

A 
Vascular access
MAP 85-100
Ephedrine > Phenylephrine
Avoid direct vasoconstriction
Heparin intraop
Foley catheter
Regional block postop pain management
NO nitrous oxide (interferes w/ healing)
38
Q

Dextran

A

Flap procedures
Reduces clot formation in microvasculature
25-30mL/hr (low molecular weight)
Monitor allergic reactions ARDS

39
Q

Breast Reduction

A

Reduction mammoplasty
Inferior pedicle w/ long curved horizontal incision across crease beneath breast
Inferior pedicle w/ vertical incision & short horizontal at crease (less scaring & shorter time)
+/- liposuction

40
Q

Breast Reduction

Anesthetic Considerations

A 
General
Frequent position changes
3-5hrs +
Fluid warmer
Bair hugger
Foley catheter
Fluid/blood volume deficits
PONV
24hr stay
41
Q

Breast Reduction

Complications

A 
Wound dehiscence 
Infection
Seroma
Hematoma
Skin flap necrosis
Loss sensation
Hypertrophic scarring
42
Q

Abdominal Surgeries

A 
Liposuction
360° liposuction
Abdominoplasty
Tummy tuck
Abdominal muscle repair
Mommy makeover
43
Q

Liposuction

A

2nd most common plastic surgery procedure
Removes fat from unwanted areas
Potential fat redistribution
Abdomen, hips, waist, torso, neck, extremities, pectoral region
Preop assess for cardiomyopathy, pulmonary disease, pulmonary embolus, thrombophilia
Relatively low risk procedure
Do not exceed 5% body weight (total volume < 5L)
Hypervolemia → hypovolemia, bleeding, electrolyte disturbances

44
Q

What plastic surgery procedure has the highest morbidity & mortality?

A

Liposuction

45
Q

Liposuction

Dry Technique

A

Not recommended
Aspiration cannula inserted into space where fat will be removed
EBL 20-45% volume aspirated

46
Q

Liposuction

Wet Technique

A

200-300mL solution injected into each area to be treated

EBL 1% volume aspirated

47
Q

Liposuction

Super-Wet Technique

A

Infiltrated solution = amount fat to be removed 1:1 ratio

EBL 1% volume aspirated

48
Q

Liposuction

Tumescent Method

A

3-4mL solution per mL expected aspirate injected into fatty tissue
EBL 1% volume aspirated

49
Q

Tumescent Solution

A

Removal SQ fat under anesthesia infiltrated w/ saline solution w/ Epi & Lidocaine
Used w/ general, spinal, or epidural
Requires monitoring, cardiac resuscitation, ventilatory support, recovery under anesthesia care

50
Q

Klein’s Solution

A

1% Lidocaine 50mL
1:1,000 Epi 1mL
8.4% NaH2CO2 12.5mL
1,000mL NS

51
Q

Hunstad Solution

A

1,000mL LR (no burning sensation d/t reduced Na+ load)
1% Lidocaine 50mL
1:1,000 Epi 1mL
NO bicarbonate

52
Q

Lidocaine Maximum Dose

A 
FDA 35mg/kg (total body weight)
Dermatology or plastic surgery 55mg/kg
Anesthesiology 5mg/kg
Lidocaine w/ Epi 500mg
Epi 1:200,000 ↓SQ lidocaine absorption 50%
53
Q

Total Adrenaline Maximum

A

50mcg/kg

54
Q

Bicarbonate

A

↑pH
Helps to reduce pain
Facilitates faster entry into nerve cell where lidocaine acts therefore quicker onset

55
Q

Liposuction

Complications

A 
LAST
Hypothermia
Fat embolism
DVT/PE
Acute anemia
Pulmonary edema
Fluid overload
Hemorrhage
Electrolyte imbalances
Nerve damage
Epi toxicity
Death
56
Q

Liposuction

IVF Management

A

< 4L = maintenance only
> 4L = MIVF + 0.25mL per mL removed after 4L
Goal to maintain normal intravascular volume w/ post-anesthetic Hct > 30% & albumin > 3g

57
Q

Liposuction

Anesthetic Considerations

A 
General anesthesia
SCDs DVT/PE prophylaxis
Foley, Bair hugger, fluid warmer
Close incision sites w/ sterile dressings
Compression garment (binder)
Postop pain r/t amount fat removed 
Tissue trauma d/t suctioning
58
Q

360° Liposuction

A

Entire truncal midsection
Goal to complete curvier contour from every angle
Combination w/ dermolipectomy, rectus abdominis muscle plication, umbilicoplasty, or gluteal fat grafting

59
Q

Abdominoplasty

A

Abdominal wall surgery
Umbilicus circumcised & blood supply preserved
Resect excess skin (pubis to costal margin)
Semi Fowler position on emergence & extubation
Combined w/ liposuction → lipoabdominoplasty

60
Q

Abdominoplasty

Anesthetic Considerations

A

2-5hr
Post gastric bypass ensure patients have stable weight 6mos prior to surgery
CBC, BMP, EKG, HFP
General anesthesia
Fluid warmer, Bair hugger, Foley, PIV, antibiotics
Prevent tension on suture lines (flexed table during surgical closure)
Postop PCA

61
Q

Abdominoplasty

Complications

A 
Ileus
Infection
Dehiscence
Fat embolism
DVT
62
Q

Mommy Makeover

A

Goal to restore shape & appearance after childbearing
Typically performed as single-stage procedure
Breast augmentation or lift, buttock augmentation, liposuction, tummy tuck, vaginal rejuvenation
Prevent DVT/PE, infections, postop pain
Abdominal contour surgeries consider spinal block up to T4

63
Q

Autologous Fat Grafting

A

Transfer fat from one or more areas to other areas in order to improve body contour
Natural filler
Available & easy to obtain
Unpredictable % reabsorption
Most frequent areas = hips, buttocks, breast, face, & hands
Spinal > general anesthesia

64
Q

Autologous Fat Grafting

Phases

A
  1. Harvesting adipose tissue
  2. Processing lipoaspirate
  3. Reinjection into receptor site
65
Q

Cosmetic Facial Surgeries

A 
Rhytidoplasty
Eyebrow lift
Rhinoplasty
Blepharoplasty
Buccal fat removal
Lip lifts
Chin implants
66
Q

Rhytidoplasty

A

Face lift
Local anesthesia (subcutaneous & nerve blocks) + conscious sedation
Pre-medication (Melatonin, Lorazepam, Clonidine, Morphine, Fentanyl)
PONV prophylaxis
NO paralysis
Smooth emergence

67
Q

Most common complication associated w/ rhytidoplasty:

A

Hematoma

68
Q

Eyebrow Lift

A

Brow resuspension
Hair-line incision w/ flap
Possible laser use

69
Q

Blepharoplasty

A

Lid lift
Periorbital fat manipulation
Possible laser use

70
Q

Blepharoplasty Complications

A

Retrobulbar hematoma & blindness

Occulocardiac reflex → bradycardia & hypotension

71
Q

Facial Surgery

Anesthetic Considerations

A

Brow, face, & lid lifts

Supine w/ HOB rotated away
LA w/ Epi
Antibiotics
Steroids
1-2hr procedures
Outpatient
Occulocardiac reflex → bradycardia & hypotension
LA w/ sedation - patient able to open & close eyes during procedure
72
Q

Rhytidoplasty

A

Corneal protection
Nasal oxygen
Maintenance w/ Ketamine, Midazolam, Propofol, Dexmedetomidine, & opioids
Avoid general anesthesia (reserve for complex patients unable to tolerate/cooperate w/ conscious sedation)
Muscle relaxation not needed
Avoid coughing on extubation d/t bleeding at surgical site

73
Q

Rhinoplasty

A

Nose surgical manipulation - aesthetic and/or functional improvement
Find out diagnosis/indication (billing)
Septorhinoplasty includes septum repair
Augmentation w/ silicon, gortex, synthetic material, cadaveric or autologous tissue (rib, cranium, iliac crest)
Open and/or closed surgery
Splint w/ nasal packing
Outpatient procedure

74
Q

Rhinoplasty

Anesthetic Considerations

A

MAC w/ infraorbital/nasocillary block
- Vasocontrictor-soaked packed placed prior to induction
- Safer to use general when ↑blood pooling
General anesthesia
- Regular ETT or oral RAE
- OG tube to remove blood in stomach
- HOB elevated
- Nasal packing (educate patient to breath through mouth)
- Smooth emergence
- PONV prophylaxis
Rotate HOB away from anesthesia gas machine (consider positioning & vascular access)

75
Q

COMPLICATIONS & DEATH

A

Bronchospasm
Deep sedation
Illicit drug use
Thromboembolism

76
Q

How to prevent poor outcomes?

A

Appropriate pre-anesthetic evaluation
Informed consent
Appropriate monitoring
Appropriate anesthesia & postanesthetic care

77
Q

DVT/PE Prophylaxis

A

Compression stockings
Intermittent pneumatic compression tools SCDs
Venous foot pumps
Low molecular weight heparin

78
Q

What contributes to anesthesia complications?

A

Longer anesthesia times
↑complication risk
Bleedings, atelectasis, DVT/PE, immune response

79
Q

PONV Complications

A

Most common & unfavorable complication after surgery

↑bleeding, delayed discharge, $$$

80
Q

PONV Treatment

A 
Dexamethasone & Ondansetron useful & low cost
10mg Propofol (1-2cc)
81
Q

Burns

A

Wound coverage w/ autograft or synthetic/biological dressing
Early & frequent eschar removal
Debridement every 2-3 days

82
Q

Tangential Excision

A

Eschar slices are shaved sequentially until healthy wound bed developed
Epi & tourniquet per surgeon to prevent & ↓blood loss

83
Q

Facial Excision

A

Removes eschar & underlying tissues down to the muscle fascia
More rapid & less blood loss than tangential excision
Cosmetic deformities & functional loss may occur

84
Q

Burn

Anesthetic Considerations

A

Surgery scheduled once patient fluid resuscitated
Performed every 2-3 days
Endpoint = OR time > 3hrs, core temp < 35°C, blood loss > 10 units PRBCs
Type & screen w/ PRBCs present in room & on hold
Room temp 82-100°F
Caution w/ Epi
Antibiotics & antisepsis
ICU
Pain management

85
Q

Rule of 9s

A

Estimate burn severity
18-40% mortality correlates w/ burn area

Head 9%
Anterior chest 18%
Posterior chest 18%
Arms 9% each
Legs 18% each
Perineal 1%
86
Q

Burns Preop

A

Assess respiratory involvement (upper or lower airway)
Inhalational smoke/burns → airway edema
Cardiac hypermetabolism
nAChR up-regulation ↓sensitivity to NDMR ↑K+ w/ Succinylcholine
Hct/Hgb & coags
PIV vs. central line

87
Q

Burns Intraop

A

OPIOIDS/NARCOTICS
GETA (no LMA d/t airway edema)
Potentially suture ETT when facial burns present
Induction w/ Ketamine or Etomidate
> 30% total body surface area burns ↑NDMR dose

88
Q

Burns Maintenance

A

Respiratory compromise + hypermetabolic state → ↑minute ventilation, inspiratory pressures, PEEP
Warm room & IV fluids
Prepare for blood loss
- Large bore PIVs x2, cordis, and/or CVC
- Blood loss 200mL per 1% body surface area excised & grafted

89
Q

Burns Emergence

A

Narcotic use & fluid resuscitation - remain intubated
Transport w/ monitor, emergency meds/airway, PEEP
Monitor labs

AS - N931 Advanced Principles of Anesthesia (17 decks)

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