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SEE > SEE: ANESTHESIA Special Pop: ABDOMINAL/ExtraThoracic > Flashcards

SEE: ANESTHESIA Special Pop: ABDOMINAL/ExtraThoracic Flashcards

1
Q

Issues specific to abdominal cases

A 
Fluid status
Hypovolemia 
Metabolic hematologic derangements
Length of surgery
Post op course anticipated
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2
Q

All patients for emergency abdominal procedures are considered

A

FULL STOMACHs.

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3
Q

If the patient volume status of a patient cannot be deter-mined by clinical assessment alone, then

A

invasive monitoring may be required.

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4
Q

Values that can aid in estimating volume status without the risks associated with central line placement

A

pulse pressure variation (PPV) and systolic pressure variation (SPV)

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5
Q

SPV that indicates dehydration

A

5 mmhg

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6
Q

SVV that indicates dehydration

A

13-15%

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7
Q

PPV indicate that patient will be volume responsive

A

13-15%

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8
Q

Electrolytes imbalance common in patients with large gastric losses?

A

Hypokalemic Metabolic alkalosis.

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9
Q

Emergency abdominal procedure require

2 potential good way to intubate.

A

RSI with the use of cricoid pressure

OR awake intubation technique

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10
Q

Has cricoid pressure been shown to reduce risk of aspiration on induction

A

NO

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11
Q

Medication that decreases gastric acidity

A

H2 antagonist

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12
Q

Medication that decreases gastric VOLUME

A

Metoclopramide

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13
Q

Metoclopramide contraindicated in what kind of cases

A

BOWEL OBSTRUCTION.

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14
Q

Disadvantages of GA

A

loss of airway reflexes which increase the risk of aspiration

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15
Q

Innervation of the abdominal wall via the

A

Anterior division of the thoracolumbar nerves T6-L1

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16
Q

Single dose technique regional require surgery of less than

A

3 hours

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17
Q

Surgery of where in the abdomen is not well tolerated under GA ?

A

Above umbilicus T10

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18
Q

Upper abdominal procedures may require sensory level to

A

T2-T4

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19
Q

Intraperitoneal air or UPPER abdominal exploration produces a pain where?

A

DULL pain , referred to a C5 distribution usually over the shoulders.

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20
Q

Advantages of awake procedures

A

Maintain ability to communicate symptoms

Airway reflexes

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21
Q

Sympathectomy effect on bowel?

A

increase blood flow to bowel.

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22
Q

Effects of sympathectomy with neuraxial

A

Lead to vaso/venodilation and bradycardia that can lead to hypotension .

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23
Q

With unopposed parasympathetic activity what happens to bowel? how can you treat?

A

They contract and make construction of bowel anastomosess more difficult. Glycopyrrolate 0.2 to 0.4 mg IV or glucagon 1mg

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24
Q

What are the most common peripheral nerve blocks performed on the abdominal wall ?

A

TAP blocks
Rectus sheaths blocks
Subscostal TAP blocks

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25
Q

TAP block, the needle is placed in the

A

Anterior axillary line between the costal margin and the illiac crest.

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26
Q

TAP Block the LA spreads between

A

Tranversus abdominis and INTERNAL OBLIQUE Muscle planes.

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27
Q

TAP block is used for what kind of abdominal procedures?

A

Lower abdominal procedures.

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28
Q

Midline procedure of the abdomen block is

A

Rectus Sheath blocks

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29
Q

Rectus SHEATH block where is the LA deposited?

A

between rectus muscle and posterior rectus sheath.

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30
Q

What is the difference between a TAP block and a subcostal TAP block?

A

subcostal needle place more superior and lateral below coastal margin.

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31
Q

Upper nerve fibers in particular ______are more likely anesthesized with the subcostal type of TAP block

A

T8-T10

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32
Q

Very long vases with significant bowel exposure and preop hypovolemia require fluid replacement of up to_____? More restrictive approach however may lead to

A

10-15 ml/kg ; faster recover and fewer complications

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33
Q

Protocol fluid admin reduce

A

Impairement of bowel motility.
Cardiopulmonary complications
bowel edema
Reduce LOS.

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34
Q

Key point for fluid management in abdominal cases

A

more restrictive administration of intraoperative fluids in a deliberate, planned, manner appear to improve outcomes.

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35
Q

Insensible fluid losses likely range from ____For large abdominal cases.

A

0.5 ml to 1ml/kg/hr

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36
Q

Abrupt drainage of ascitic fluid with surgical entry into the peritoneum can produce

A

Acute hypotension from sudden decrease of intraabdominal pressure and POOLING OF BLOOD IN MESENTERIC VESSELS –> Reduced venous return to the right heart.

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37
Q

Fluid losses should be replaced with

A

Crystalloids,
Colloids,
Blood products

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38
Q

Initial fluid resuscitation should be made with

A

Crystalloids (isotonic salt solution)

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39
Q

Aggressive NS use may cause this imbalance

A

Non-anion GAP metabolic acidosis

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40
Q

What are colloids:

A

Fluids containing particles large enough to exert ONCOTIC PRESSURE

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41
Q

What is the difference between colloids and crystalloids?

A

Colloids REMAIN in the INTRAVASCULAR SPACE LONGER

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42
Q

Disadvantage of colloids to crystalloids

A

Expensive

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43
Q

When is albumin preferred than crystalloids?

A

significant burns
Hepatorenal disease
ALI

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44
Q

Why are Hydroxyethyl starch solutions (non blood derived colloids) falling out of favor for volume expansion?

A

Because of their deleterious effects on renal function, coagulation , may cause mortality.

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45
Q

What is required for all but the most superficial intra-abdominal procedures?

A

Muscle relaxation

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46
Q

Why is sufficient relaxation needed for abdominal surgeries?

A

Bowel distention

Edema can increase the volume of abdominal contents

47
Q

How do you titrate muscle relaxants?

A

Titrate to obtain a SINGLE twitch by TOF monitoring

48
Q

Use of N2O may cause what in abdominal surgeries. how?

A

Use of nitrous can cause bowel distention, because nitrous diffuse into the bowel lumen faster than nitrogen can diffuse out with the amount of distention depending on the concentration of N2O delivered, The blood flow to the bowel and the duration of Nitrous administration

49
Q

When can nitrous safely be used?

A

N2O may be used in shorter < 3 hours open or laparoscopic surgeries without causing clinically significant bowel distention.

50
Q

Use of N2O relatively contraindicated in

A

Bowel obstruction.

51
Q

Trial that did not prove Nitrous oxide related signiificant adverse outcomes

A

ENIGMA

52
Q

When is NG tubes indicated?

A

Trauma victims
Obstructed bowels
DECOMPRESSION of stomach needed

53
Q

Before induction, NG tube

A

Suction should be applied to NG tubes.

54
Q

What can prevent passive reflux when an NG tube is present?

A

Cricoid pressure

55
Q

Intraoperative placement of NG tube can be accomplisehd by

A

using a finger within the oropharynx or using MAGILL FORCEPS under direct visualization with a laryngoscope

56
Q

Complications of NG tube insertion include

A

bleeding

Insertion in the trachea.

57
Q

NG tube complications in a neuro patient

A

Intracranial placement in patient with BASILAR FRACTURE>

58
Q

Common intra-operative problems associated with abdominal surgery : Pulmonary

A

Surgical retraction of abdominal viscera for exposure
Insufflation of gas during Lap cases
Trendelenburg positioning

59
Q

Effect of insufflation and trendelenburg positioning.? How can you counter these Effects?

A

Elevate the diaphragm( cephalad)
Decrease FRC
Hypoxemia

Counter these effects by applying PEEP

60
Q

Common intra-operative problems associated with abdominal surgery : Temperature

A

Heat loss common

61
Q

Hemodynamic changes associated with bowel manipulation ?

A

Hypotension
Tachycardia
Facial flushing.
Abdomen inflation .

62
Q

Ischemic bowel patients may have

A

hypotension from SIRS AND SEPSIS.

63
Q

What are the early warnings for postop abdominal compartment syndrome

A

Hemodynamic instability

Difficult ventilation

64
Q

What are the BASIC tenets of Enhanced Recovery after surgery (ERAS)

A 
Regional techniques use more
Early feeding and ambulation
Multimodal analgesia
Reduced NPO times
Enhanced recovery , reduced LOS
Goal directed fluid
65
Q

Clear liquids given to ERAS

A

Clear fluid containing significant carbohydrate content are given 2-3 hours before surgery

66
Q

NPO time for ERAS

A

Generally 6 hours

67
Q

ERAS fluid preferred

A

LR, and plasmalyte preferred to NS because NS can cause metabolic acidosis

68
Q

Total perioperative fluids and ERAS

A

MInimized

69
Q

Benefits of laparoscopic surgeries as far as incision, pain, ambulation, LOS and return to normal activities

A

Smaller incision
Reduced post op pain
shorter LOS
Early return to normal activities.

70
Q

Lap surgery and post op ileus

A

Decrease

71
Q

Laparoscopic techniques explain– >

A

Intraperitoneal insufflation of CO2 through a needle inserted, into the abdominal below umbilicus

72
Q

CO2 insufflation until intra-abdominal pressure reaches 1

A

12-15 mmHg

73
Q

What position facilitates visualization of upper abdominal structures? US

A

Steep reverse Trendelenburg

74
Q

What position facilitates visualization of lower abdominal structures? LT

A

Trendelenburg

75
Q

What are the changes seen with laparoscopy inflused by ?

A

Intra-abdominal pressure needed to create the pneumoperitoneum
Volume of CO2 absorbed
The patient’s intravascular stats
Positioning and anesthetic agents.

76
Q

Effects of pneumoperitoneum on MAP and SVR?

A

Usually increase MAP and SVR

77
Q

Effects of pneumoperitoneum on CO on Healthy patients?

A

CO unaffected.

78
Q

ffects of pneumoperitoneum on CO for patients with cardiac issues?

A

Decrease CO and hypotension

79
Q

When CO2 is absorbed accross the peritoneal surface it can cause

A

Hypercarbia that can lead to SNS stimulation and increase BP , HR, and CO

80
Q

General anesthesia effect on FRC and how does pneumoperitoneum affect it?

A

GA reduces FRC and it’s worsened by pneumoperitoneum.

81
Q

FRC is further reduced because (aside from GA and pneumoperitoneum) how do you deal with it

A

Body habitus
Trendelenburg
Frequent recruitment and HIGH PEEP may be necessary to treat alveolar collapse.

82
Q

Pt in steep trendelenburg position may be at risk for

A

Changes in vernous return

83
Q

This nerve injury may occur with Trendelenburg or steep trendelenbury?

A

Brachial plexus injury

84
Q

Diffusion of gas cephalad from the mediastinum can lead to

A

Subcutaenous emphysema of the face and neck

85
Q

Vascular injuries 2nd to the introduction of the trocar can produces

A

sudden blood loss and may convert to open procedure to prevent bleeding.

86
Q

Venous gas embolism can occur

A

If trocal is placed into a vessel or if the gas is trapped in the portal circulation

87
Q

Insufllation of gas under high pressure in the stomach can lead to a

A

Gas lock into the vena cava and RA–> decrease VR, and CO and produce circulatory collapse.

88
Q

Embolization of the pulmonary circulation leads to

A

increased dead space
V/Q mismatch
Hypoxemia

89
Q

how can systemic embolization occur

A

Massive gas in a patent foramen ovale.

90
Q

Treatment of suspected embolization

A

Stop insufflation
Give 100% O2
Place patient in STEEP head down and LEFT LATERAL DECUBITUS patient to deplace gas from RV outflow tract.

91
Q

Preferred anesthesia type for Laparoscopic procedures

A

GA

92
Q

What is the most common surgical treatment for reflux disease?

A

Nissen fundoplication

93
Q

What is the nissen fundoplication

A

Wrapping fundus of the stomach around the esophagus

94
Q

Also repaired during the nissen fundoplication

A

Hiatal hernia

95
Q

Patients with nissen fundoplication usually are on _______and you should

A

H2 receptor antagonists or prokinetic agents

Continue up until the day of surgery,.

96
Q

What may be placed to calibrate fundoplication?

A

Esophageal bougie, to ensure an adequate esophageal lumen to minimize post op dysphagia.

97
Q

Possible complication of bougie insertion

A

perforation

98
Q

Billroth I is a

A

GastroDUODENOSTOMY

99
Q

Billroth II is a

A

GastroJEJUNOSTOMY

100
Q

Gastric surgery patients are at risk for ____therefore types of intubation required are

A

aspiration , RSI or awake intubation

101
Q

Indications for SB resection include

A 
infection
Crohn
Trauma
Intussusception 
Meckel diverticulum
102
Q

Appendectomy performed through 2 ways

A

small lower abdominal incision or laparoscopy

103
Q

Appendectomy anesthesia

A

GA with RSI or awake intubation, consider TAP blocks

104
Q

Colectomy used to treat

A

colon Ca
Crohn’s
UC
ischemic colitis

105
Q

Emergency colectomy on unprepared bowel carries high risk of

A

peritonitis from fecal contamination

106
Q

PAtients for emergent colon surgeries should be evaluated for

A

Anemia
Hypovolemia
Sepsis

107
Q

Preferred anestheisa for colectomy or colon surgery

A

Combined GA and regional

108
Q

Abcess drainage and hemorrhoidectomy can be performed in 2 positions

A

Prone or lithotomy

109
Q

If GA is used for hemorrhoidectomy

A

Deep anesthesia to achieve adequate SPHINCTER RELAXATION .

110
Q

Types of SPINAL anesthesia for lithotomy vs flexed prone or knee chest position

A

Hyperbaric for lithotomy position

Hypobaric for flexed prone or Jackknife

111
Q

hernia repair surgeries can be performed under

A

GA, or regional with LA, .

112
Q

During hernia surgeries

A

Maximal stimulation and profound vagal responses may occur during SPERMATIC CORD or PERITONEAL TRACTION

113
Q

May occur during SPERMATIC CORD or PERITONEAL TRACTION ?? what is critical?

A

Maximal stimulation
Profound vagal responses
COMMUNICATION WITH SURGEON IMPORTANT TO REDUCE TRACTION if necessary

114
Q

Abdominal surgeries and emergence

A

Minimize coughing on emergence that can strain the repair

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