Test 3 Flashcards
Laparoscopy
Effects of pneumoperitoneium
Resp
Cardiac
-Intraperitoneal insufflation of CO2
-Release of catecholamines and vasopressin
-Increased PaCO2
-Decrease compliance/FRC
-Gas embolism, pneumo, endotracheal intub
-Increase BP and SVR
-Decrease CO
**Bradycardia = Glycopyyrolate
*Brady does not correlate with ETCO2
-Gas embolism. L>?? Tx?
-Subqemphysema
-Pneumothorax
-Pneumomediastium
-Endobronchial intubation
Gas embolism
-Tachycardia + Hypo
-Decrease ETCO2
-Millwhell murmur
–> Tx: Tredenlengburg, fluid bolus, O2, aspirate air
Improper placement of trochar but resolves in ~30-60mins
Cephalad movement of carina from tredenlenburg position
Tredenlengburg
(Head down)
Reverse Tredelenburg
(Head up)
T = ^CO, VR, IABP, IOP
Decrease FRC/compliance
Reverse T=
–> Hypotension, decrease CO, **Venous stasis
:) for breathing
Complications of laparoscopy (4)
Contraindications? (4)
Considerations for anesthesia?
-30-50% = performation/CBD injury
-15-30% = Burns
-Retroperitoneal hematomas (often insidious)
-Infection
Contra= Increase ICP, tumor, trauma, hydrocephalus
Anesthesia: OG, T = intubate, light pressure = LMA, NMBD, narcotics
Nissen fundoplication
What is the surgery for? indications?
Pre-op
Intra-op
Positions?
–>To increase lower esophageal sphincter pressure
–>Complications of GERD
-Stricture
-Aspiration pneumonia
-Esophageal ulcerations
-Barrett’s esophagus
-Failure or unwillingness to commit to medication
Pre-op=
PPI, Pro-kinetics, document eso hyperacidity
Intra-op=
-OG decompress,
-Esophageal dilator = lube+ leave til surgeon suture then pull out
-Anti-biotics
Position??
Supine, low lithotomy, reverse Tburg
Cholecystectomy= remove Gallbladder
Indications? 5 Fs
Pre-op
Intra-op
Position?
Symptomatic cholecystitis=
–>5 F’s: female, forty, fair, flatulent, fat
Pre-op:
Full stomach = prokinetics
Bicitra
Position?
Supine, reverse Tburg, left tilt
Glucagon= for sphincter of oddi spasm
SpLLLenectomy
Indications?
***Position?
Pre-op? week before? labs?
Intraop?
Indications: THINK BLEEDING
ITP
Lymphoma
Hemolytic anemia
Trauma
Preoperatively
Should have received pneumococcal, meningococcal, and H influenza vaccinations 1 week preop
Evaluate LLL atelectasis
Intraoperatively
GETA
–>Type and cross
vs type and screen
Xtra venous access
-SCIP antibiotics
Position
45 degree right lateral decubitus=Kidney rest, table flexed
Bowel resection
Indications?
Pre-op
Meds?
Intra-op
Position:
Indications
Ulcerative colitis
Crohn’s disease
Diverticular disease
Cancers
Ischemic bowel
Preoperatively
Bowel prep
Mu-opioid antagonists
Entereg (alvimopan)
ERAS/ (multimodal)
Preop warming
MEDS??
Gabapentin, acetaminophen, scopolamine
Gatorade
Intraoperatively
GETA
OG vs. NGT
SCIP antibiotics
Consider albumin vs crystalloid
Postop pain control
Position
Supine or low lithotomy
Appendectomy
Pre-op? Symptoms to look for?? Labs?
Intra-op?
Position? what armed tucked?
Preoperatively
Consider full stomach
May be dehydrated d/t fever/N&V
-Hemoconcentration
-elev. BUN
Intraoperatively
GETA
Consider full stomach/aspiration risk
OGT
SCIP antibiotics
Position
–>Supine, left arm tucked; trendelenburg
Bariatric Surgery
Obesity + symptoms
Pre-op– prophylaxis
Intra-op
POSITION? Whats good for breathing??
When to remove OG tube?
Preoperatively
-Review medication list- appetite suppressors?
-Assess airway- limit preoperative sedation?
-Commonly have undiagnosed OSA
VTE prophylaxis!!!
POSITION: Reverse Tburg/HOB up 30 degrees…..GOOD pre-oxygenation
Intraoperatively
–>GETA/RSI- supine position=too hard to mask ventilate
–> Induction on ideal body weight
OGT- removed before stomach stapled
Calibration tube/methylene blue
Long term concerns for bariatric surgery
Types:
1.) Lap banding
2.) Sleeve Gastroectomy
3.) Gastric bypass
Long term complications: Diarrhea, dysphagia, protein and vitamin malabsorption
A,D,E,K,B12,calcium
Laparotomy
Indications?
Indications for conversion
Obesity
Adhesions
Bleeding
Unclear anatomy
Staple misfire
Inability to ventilate
Exploratory laparotomy
pre-op?
intra-op?
Indications
-Trauma
-Abdominal catastrophes
-Staging
Intraoperatively
-GETA
-Profound muscle relaxation
-NGT—manipulate the bowel. Will have ileus
-Consider epidural placement
-Consider multi-modal pain control
-Keep warm!!!
Gynecological
D & C (Dilation and Curettage)
Pre-op
Intra-op
Type of anesthesia?
Meds???
Removes excess uterine/endometrial lining
Pregnancy test
Stop breast feed
General anesthesia
L> Bradycardia
Pitocin IV
NOOOO SCIP ANTIBIOTICS
D & E
how many weeks counseling period??
Anesthesia involvement?
Variable by state
-20-24 weeks
-Counseling/Waiting period
-Parental involvement
Anesthesia involvement
–>Pitocin IV
Pitocin
How many units/L?
Secreted from ___?
Mechanism of Action?
-Secreted from the neuro-hypophysis
-Stimulates uterine contraction
-Similar to vasopressin
–>Increases water reabsorption from glomerular filtrate
20u/liter
Hysteroscopy
What is the purpose of this procedure?
How to prep?
Intraop? Symptoms to L>?
Examine endometrial cavity/ Look for IUB
Need inflate uterus:
1.) NS/LRS
2.) Sorbitol
Intra-op
-Paracervical block vs gen anesthesia
-Lithotomy
-BRADYCARDIA
-Anti-biotics
Urethral slings
For what population of patients?
What kind of anesthesia?
Position?
For incontinence/ loss support to bladder neck and pelvic floor:
1.) Jumping sports
2.) Older/ lots of babies
Prolene mesh
Intraoperatively
Lithotomy
General anesthesia
LMA— quick
SCIP antibiotics
Post op pain? (tender)
Condyloma—Genital warts from HPV
What to be aware of during surgery??
Intraoperatively
Lithotomy
General anesthesia—LMA
Laser evacuation procedures!!!!!
LASER MASK
Smoke evacuation—bc BURNING off the CONDYLOMA
Repair procedures
-Caused by weakened pelvic floor
-Delivery…repair postponed…
–>Aging
–>Previous pelvic
Types (3): CRE
Position?
Intra-op?
Types
1.) Cystocele- Anterior prolapse
2.)Rectocele- Posterior prolapse
3.) Enterocele
Intra-op
-General anesthesia
-SCIP
-**Foley Catheter (if longer than 3 hrs)
Hysterectomy/BSO
Where is the incision??
Abdominal= ___
Vagina =____
Abdominal: Pfannenstiel or midline
Vaginal:
LAVH—Laparoscopic- assisted combined hysterectomy
Intraoperatively
Position???
General anesthesia
GETA
Foley catheter
SCIP
Bowel prep??— depends on surgeon
**Bradycardia??
88–> pulling on peritoneium or cervix
PONV??
Robotic surgery
(Improved dexterity but also increased cost)
Positions??
Intra-op considerations??
Position=
-EXTREME TRENDELENBURG
= Head down
GOOD MUSCLE RELAXATION
FLUID RESTRICTION = bc fluid will go to head/airway.
Pressors > Fluids
-Anti-biotics
