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
2
Q
All patients for emergency abdominal procedures are considered
A
FULL STOMACHs.
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.
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)
5
Q
SPV that indicates dehydration
A
5 mmhg
6
Q
SVV that indicates dehydration
A
13-15%
7
Q
PPV indicate that patient will be volume responsive
A
13-15%
8
Q
Electrolytes imbalance common in patients with large gastric losses?
A
Hypokalemic Metabolic alkalosis.
9
Q
Emergency abdominal procedure require
2 potential good way to intubate.
A
RSI with the use of cricoid pressure
OR awake intubation technique
10
Q
Has cricoid pressure been shown to reduce risk of aspiration on induction
A
NO
11
Q
Medication that decreases gastric acidity
A
H2 antagonist
12
Q
Medication that decreases gastric VOLUME
A
Metoclopramide
13
Q
Metoclopramide contraindicated in what kind of cases
A
BOWEL OBSTRUCTION.
14
Q
Disadvantages of GA
A
loss of airway reflexes which increase the risk of aspiration
15
Q
Innervation of the abdominal wall via the
A
Anterior division of the thoracolumbar nerves T6-L1
16
Q
Single dose technique regional require surgery of less than
A
3 hours
17
Q
Surgery of where in the abdomen is not well tolerated under GA ?
A
Above umbilicus T10
18
Q
Upper abdominal procedures may require sensory level to
A
T2-T4
19
Q
Intraperitoneal air or UPPER abdominal exploration produces a pain where?
A
DULL pain , referred to a C5 distribution usually over the shoulders.
20
Q
Advantages of awake procedures
A
Maintain ability to communicate symptoms
Airway reflexes
21
Q
Sympathectomy effect on bowel?
A
increase blood flow to bowel.
22
Q
Effects of sympathectomy with neuraxial
A
Lead to vaso/venodilation and bradycardia that can lead to hypotension .
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
24
Q
What are the most common peripheral nerve blocks performed on the abdominal wall ?
A
TAP blocks
Rectus sheaths blocks
Subscostal TAP blocks
25
TAP block, the needle is placed in the
Anterior axillary line between the costal margin and the illiac crest.
26
TAP Block the LA spreads between
Tranversus abdominis and INTERNAL OBLIQUE Muscle planes.
27
TAP block is used for what kind of abdominal procedures?
Lower abdominal procedures.
28
Midline procedure of the abdomen block is
Rectus Sheath blocks
29
Rectus SHEATH block where is the LA deposited?
between rectus muscle and posterior rectus sheath.
30
What is the difference between a TAP block and a subcostal TAP block?
subcostal needle place more superior and lateral below coastal margin.
31
Upper nerve fibers in particular ______are more likely anesthesized with the subcostal type of TAP block
T8-T10
32
Very long vases with significant bowel exposure and preop hypovolemia require fluid replacement of up to_____? More restrictive approach however may lead to
10-15 ml/kg ; faster recover and fewer complications
33
Protocol fluid admin reduce
Impairement of bowel motility.
Cardiopulmonary complications
bowel edema
Reduce LOS.
34
Key point for fluid management in abdominal cases
more restrictive administration of intraoperative fluids in a deliberate, planned, manner appear to improve outcomes.
35
Insensible fluid losses likely range from ____For large abdominal cases.
0.5 ml to 1ml/kg/hr
36
Abrupt drainage of ascitic fluid with surgical entry into the peritoneum can produce
Acute hypotension from sudden decrease of intraabdominal pressure and POOLING OF BLOOD IN MESENTERIC VESSELS --> Reduced venous return to the right heart.
37
Fluid losses should be replaced with
Crystalloids,
Colloids,
Blood products
38
Initial fluid resuscitation should be made with
Crystalloids (isotonic salt solution)
39
Aggressive NS use may cause this imbalance
Non-anion GAP metabolic acidosis
40
What are colloids:
Fluids containing particles large enough to exert ONCOTIC PRESSURE
41
What is the difference between colloids and crystalloids?
Colloids REMAIN in the INTRAVASCULAR SPACE LONGER
42
Disadvantage of colloids to crystalloids
Expensive
43
When is albumin preferred than crystalloids?
significant burns
Hepatorenal disease
ALI
44
Why are Hydroxyethyl starch solutions (non blood derived colloids) falling out of favor for volume expansion?
Because of their deleterious effects on renal function, coagulation , may cause mortality.
45
What is required for all but the most superficial intra-abdominal procedures?
Muscle relaxation
46
Why is sufficient relaxation needed for abdominal surgeries?
Bowel distention
| Edema can increase the volume of abdominal contents
47
How do you titrate muscle relaxants?
Titrate to obtain a SINGLE twitch by TOF monitoring
48
Use of N2O may cause what in abdominal surgeries. how?
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
When can nitrous safely be used?
N2O may be used in shorter < 3 hours open or laparoscopic surgeries without causing clinically significant bowel distention.
50
Use of N2O relatively contraindicated in
Bowel obstruction.
51
Trial that did not prove Nitrous oxide related signiificant adverse outcomes
ENIGMA
52
When is NG tubes indicated?
Trauma victims
Obstructed bowels
DECOMPRESSION of stomach needed
53
Before induction, NG tube
Suction should be applied to NG tubes.
54
What can prevent passive reflux when an NG tube is present?
Cricoid pressure
55
Intraoperative placement of NG tube can be accomplisehd by
using a finger within the oropharynx or using MAGILL FORCEPS under direct visualization with a laryngoscope
56
Complications of NG tube insertion include
bleeding
| Insertion in the trachea.
57
NG tube complications in a neuro patient
Intracranial placement in patient with BASILAR FRACTURE>
58
Common intra-operative problems associated with abdominal surgery : Pulmonary
Surgical retraction of abdominal viscera for exposure
Insufflation of gas during Lap cases
Trendelenburg positioning
59
Effect of insufflation and trendelenburg positioning.? How can you counter these Effects?
Elevate the diaphragm( cephalad)
Decrease FRC
Hypoxemia
Counter these effects by applying PEEP
60
Common intra-operative problems associated with abdominal surgery : Temperature
Heat loss common
61
Hemodynamic changes associated with bowel manipulation ?
Hypotension
Tachycardia
Facial flushing.
Abdomen inflation .
62
Ischemic bowel patients may have
hypotension from SIRS AND SEPSIS.
63
What are the early warnings for postop abdominal compartment syndrome
Hemodynamic instability
| Difficult ventilation
64
What are the BASIC tenets of Enhanced Recovery after surgery (ERAS)
```
Regional techniques use more
Early feeding and ambulation
Multimodal analgesia
Reduced NPO times
Enhanced recovery , reduced LOS
Goal directed fluid
```
65
Clear liquids given to ERAS
Clear fluid containing significant carbohydrate content are given 2-3 hours before surgery
66
NPO time for ERAS
Generally 6 hours
67
ERAS fluid preferred
LR, and plasmalyte preferred to NS because NS can cause metabolic acidosis
68
Total perioperative fluids and ERAS
MInimized
69
Benefits of laparoscopic surgeries as far as incision, pain, ambulation, LOS and return to normal activities
Smaller incision
Reduced post op pain
shorter LOS
Early return to normal activities.
70
Lap surgery and post op ileus
Decrease
71
Laparoscopic techniques explain-- >
Intraperitoneal insufflation of CO2 through a needle inserted, into the abdominal below umbilicus
72
CO2 insufflation until intra-abdominal pressure reaches 1
12-15 mmHg
73
What position facilitates visualization of upper abdominal structures? US
Steep reverse Trendelenburg
74
What position facilitates visualization of lower abdominal structures? LT
Trendelenburg
75
What are the changes seen with laparoscopy inflused by ?
Intra-abdominal pressure needed to create the pneumoperitoneum
Volume of CO2 absorbed
The patient's intravascular stats
Positioning and anesthetic agents.
76
Effects of pneumoperitoneum on MAP and SVR?
Usually increase MAP and SVR
77
Effects of pneumoperitoneum on CO on Healthy patients?
CO unaffected.
78
ffects of pneumoperitoneum on CO for patients with cardiac issues?
Decrease CO and hypotension
79
When CO2 is absorbed accross the peritoneal surface it can cause
Hypercarbia that can lead to SNS stimulation and increase BP , HR, and CO
80
General anesthesia effect on FRC and how does pneumoperitoneum affect it?
GA reduces FRC and it's worsened by pneumoperitoneum.
81
FRC is further reduced because (aside from GA and pneumoperitoneum) how do you deal with it
Body habitus
Trendelenburg
Frequent recruitment and HIGH PEEP may be necessary to treat alveolar collapse.
82
Pt in steep trendelenburg position may be at risk for
Changes in vernous return
83
This nerve injury may occur with Trendelenburg or steep trendelenbury?
Brachial plexus injury
84
Diffusion of gas cephalad from the mediastinum can lead to
Subcutaenous emphysema of the face and neck
85
Vascular injuries 2nd to the introduction of the trocar can produces
sudden blood loss and may convert to open procedure to prevent bleeding.
86
Venous gas embolism can occur
If trocal is placed into a vessel or if the gas is trapped in the portal circulation
87
Insufllation of gas under high pressure in the stomach can lead to a
Gas lock into the vena cava and RA--> decrease VR, and CO and produce circulatory collapse.
88
Embolization of the pulmonary circulation leads to
increased dead space
V/Q mismatch
Hypoxemia
89
how can systemic embolization occur
Massive gas in a patent foramen ovale.
90
Treatment of suspected embolization
Stop insufflation
Give 100% O2
Place patient in STEEP head down and LEFT LATERAL DECUBITUS patient to deplace gas from RV outflow tract.
91
Preferred anesthesia type for Laparoscopic procedures
GA
92
What is the most common surgical treatment for reflux disease?
Nissen fundoplication
93
What is the nissen fundoplication
Wrapping fundus of the stomach around the esophagus
94
Also repaired during the nissen fundoplication
Hiatal hernia
95
Patients with nissen fundoplication usually are on _______and you should
H2 receptor antagonists or prokinetic agents
| Continue up until the day of surgery,.
96
What may be placed to calibrate fundoplication?
Esophageal bougie, to ensure an adequate esophageal lumen to minimize post op dysphagia.
97
Possible complication of bougie insertion
perforation
98
Billroth I is a
GastroDUODENOSTOMY
99
Billroth II is a
GastroJEJUNOSTOMY
100
Gastric surgery patients are at risk for ____therefore types of intubation required are
aspiration , RSI or awake intubation
101
Indications for SB resection include
```
infection
Crohn
Trauma
Intussusception
Meckel diverticulum
```
102
Appendectomy performed through 2 ways
small lower abdominal incision or laparoscopy
103
Appendectomy anesthesia
GA with RSI or awake intubation, consider TAP blocks
104
Colectomy used to treat
colon Ca
Crohn's
UC
ischemic colitis
105
Emergency colectomy on unprepared bowel carries high risk of
peritonitis from fecal contamination
106
PAtients for emergent colon surgeries should be evaluated for
Anemia
Hypovolemia
Sepsis
107
Preferred anestheisa for colectomy or colon surgery
Combined GA and regional
108
Abcess drainage and hemorrhoidectomy can be performed in 2 positions
Prone or lithotomy
109
If GA is used for hemorrhoidectomy
Deep anesthesia to achieve adequate SPHINCTER RELAXATION .
110
Types of SPINAL anesthesia for lithotomy vs flexed prone or knee chest position
Hyperbaric for lithotomy position
| Hypobaric for flexed prone or Jackknife
111
hernia repair surgeries can be performed under
GA, or regional with LA, .
112
During hernia surgeries
Maximal stimulation and profound vagal responses may occur during SPERMATIC CORD or PERITONEAL TRACTION
113
May occur during SPERMATIC CORD or PERITONEAL TRACTION ?? what is critical?
Maximal stimulation
Profound vagal responses
COMMUNICATION WITH SURGEON IMPORTANT TO REDUCE TRACTION if necessary
114
Abdominal surgeries and emergence
Minimize coughing on emergence that can strain the repair
