Procedures Flashcards
CEA
- benefit for symptomatic patient (TIA/CV) w/>70% stenosis
- cerebral monitoring: stump pressure (>50 mmHg), EEG (raw or processed), SSEPs, transcranial doppler, cerebral oximetry
- shunting risks: air/plaque emboli, intimal tears, carotid dissection
- risks: CVA, MI, CN injury, hematoma, airway edema
- GA v RA: no difference in rate of death or stroke
- GA: controlled environment
- RA: direct neuro monitoring
- RA: superficial cervical plexus block (no added benefit w/deep cervical plexus block)
- volatile anesthetics may offer neuroprotection
- hyperperfusion syndrome post-op: HTN, headache, neuro deficits, seizures
*Cervical plexus C1-C4: deep is motor, superficial is sensory
Labor/Cesarean Section
Pain
- T10-L1: uterus/cervix
- S2-S4: pudendal nerve, perineum
Craniotomy
- brain relaxation (decrease ICP): HoB 30 degrees, propofol, hyperventilation (PaCO2~30 mmHg), mannitol (0.5 mg/kg), dexamethasone, CSF drainage
- CPP = MAP - ICP (normal ~ 80 mmHg)
- N2O: increases CBF, CMR, and ICP
Laparoscopy
- adv: reduced pain, reduced hospital stay, improved postoperative respiratory function
- CO2 absorption for pneumoperitoneum causes hypercapnia (venous gas embolus possible)
- pneumoperitoneum: increased IAP (<15 mmHg nl), bradycardia (vagal), reduced lung volumes, increased PAP, V/Q mismatch, pneumothorax, increased ICP, decreased renal/hepatic blood flow
- post-op shoulder pain common secondary to diaphragm irritation
Bleeding T&A
- hypovolemia, full stomach +/- aspiration, edematous/bloody airway, pain (uncooperative patient)
- EMERGENCY
- scan vitals and assess patient (cap refill, mucous membranes, skin turgor)
- labs if time (STAT CBC, coags, T&S)
- 2 IVs, crystalloid bolus 20 ml/kg, transport to OR with 100% 02 in lateral position and Trendelenburg
- RSI w/cricoid: ketamine 2 mg/kg and sux 2 mg/kg
- suction stomach prior to extubation
- extubate awake
TURP Syndrome
- hyponatremia
- hypo-osmolality (cerebral edema/seizures)
- fluid overload (HTN or hypotension)
- shock and CV collapse
- chest pain/dyspnea/pulmonary edema
- hyperglycinemia (blindness)
- hyperammonemia (encephalopathy)
- dysrhythmias
- hypothermia
- Prevention: short duration (<90 min), limit intravesicular pressure (<30 mmHg), use isotonic irrigation fluid (1.5% glycine is hypotonic)
- *spinal allows for earlier and easier detection
Liver Transplant/Resection
Considerations: multisystem disease
- CV: hyperdynamic circulation, increased CI, LVH, PHTN
- Resp: RLD (ascites), pleural effusion, shunting (hepatopulmonary syndrome)
- Renal: hepatorenal syndrome, ATN
- Metabolic: metabolic acidosis, hyponatremia, hyperkalemia, hypomagnesemia, hypoglycemia
- Hematology: reduced synthesis of vitamin K-dependent factors, DIC, anemia, thrombocytopenia
- CNS: encephalopathy, cerebral edema
Considerations: surgical maneuvers to reduce bleeding
- Pringle maneuver: clamp portal vein and hepatic artery (decrease CO and increase afterload)
- Total hepatic vascular occlusion: clamp supra- and infra-hepatic IVC, portal vein and hepatic artery (hypotension and decrease CO up to 60%)
Reperfusion hypotension
-ddx: hypovolemia, acidosis, hyperkalemia, hypocalcemia
*If hyperkalemia is an issue post-reperfusion but ongoing blood loss requires blood transfusion, potassium load can be minimized by having the pRBCs washed
Mediastinoscopy
Strong contraindication
-previous mediastinoscopy
Relative contraindications
-severe tracheal deviation, cerebrovascular disease, severe cervical spine disease w/limited neck extension, previous chest radiation, TAA
Complications
-tracheal compression or laceration, innominate artery compression (CVA or RUE ischemia), compression of aorta and reflex bradycardia, pneumothorax (enter pleural space), RLN or phrenic nerve injury, venous air embolism, mediastinal hemorrhage, esophageal tear
*risk of compression of the innominate artery- place arterial line and/or pulse oximeter on the right arm to monitor for compression
