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931: Advanced Principles of Anesthesia I > Types of General Surgery Part III > Flashcards

Types of General Surgery Part III Flashcards

1
Q

Common laparoscopic GI procedures include:

A

cholecystectomy- removal of disease gall bladder
herniorrhaphy- defect in muscles of abdominal wall
appendectomy- most common acute surgical procedure of the abdomen- obstruction/inflammation due to lymphoid tissue or fecal matter

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2
Q

Cholecystectomies can be performed due to

A

cholecystitis, cholelithiasis, cancer

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3
Q

Types of hernias include

A

inguinal, umbilical, incisional, abdominal, femoral, & diaphragmatic

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4
Q

Cholecystectomies can be performed

A

laparoscopic versus open
rate of conversion 5-10%
concern is a Sphincter of Oddi spasm

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5
Q

Risk factors for conversion to open for a cholecystectomy includes

A 
acute cholecystitis with thickened gallbladder wall
previous upper abdominal surgery
male gender
advanced age
obesity
bleeding
bile duct injury
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6
Q

Potential cholecystectomy complications include

A

bleeding from cystic artery & cystic duct liver laceration

pneumothorax

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7
Q

Considerations for cholecystectomy include

A

preoperative antibiotics are controversial

DVT prophylaxis

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8
Q

Positioning for cholecystectomy include

A

surgeon on patient’s left (supine) or between patient’s legs (lithotomy)
Reverse Trendelenburg, left tilt (right side up)

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9
Q

Herniorrhaphy is performed

A

outpatient, elective surgery

open versus laparoscopic

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10
Q

If a hernia is not reduced,

A

there is potential for incarceration which makes it an urgent surgery

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11
Q

Strangulated hernia is

A

an emergency surgery, GA–> can lead to necrotic bowel requiring bowel resection

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12
Q

Anesthetic considerations for hernia surgery include

A

avoid strain (smooth emergence)
anesthetic choice: GA, local, or regional (T8)
EBL~50 mL
postop pain is 4-6
LA infiltration of ilioinguinal and iliohypogastric nerves
bradycardia due to peritoneal retraction

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13
Q

GI lab diagnostics include

A

esophagogastroduodenoscopy (EGD), endoscopic retrograde cholangiopancreatography (ERCP), colonoscopy

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14
Q

Appendectomies are performed for

A

appendicitis (presenting as pain, anorexia)
mortality 1% (2% if perforated)
incidence of 6% of population

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15
Q

The anesthetic technique utilized for appendectomies includes

A

GA (RSI?), OGT, avoid N20, give antibiotics

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16
Q

Considerations for appendectomy include

A

fluid & electrolyte deficits, aspiration precautions, avoid metoclopramide with obstructions, skeletal muscle relaxation

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17
Q

Colonoscopies are done to

A

view the lining of the rectum and colon- cancer screening, treatment of polyps

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18
Q

Potential complications of colonoscopy & EGD include

A

perforation, bleeding, desaturation, and laryngospasm (due to spontaneous breathing as it is a room air general)

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19
Q

Considerations for colonoscopy include

A

colon prep, clear liquid diet

  • left lateral decubitus
  • usually heavy sedation or GA
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20
Q

Considerations/positioning for EGD includes

A

supine or lateral decubitus

conscious sedation/topical, GA

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21
Q

When performing an EGD, there is

A

shared airway/limited access
mouth-piece inserted by endoscopist to prevent biting
may consider GETA (obese, risk factors)
if there is any food that is found when endoscope is inserted then it needs to be aborted

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22
Q

Indications for esophageal surgery include

A

GERD, CA, hiatal hernia, motility disorders

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23
Q

Patient symptoms indicating need for esophageal surgery include

A

dysphagia, heartburn, hoarse voice, & chest pain

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24
Q

ERCP is performed to

A

diagnose and treat pancreatic and biliary disorders

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25
Q

Complications of ERCP include

A

perforation, bleeding, laryngospasm, and desaturation

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26
Q

Surgical considerations for ERCP include

A

GETA or sedation, length is 30 minutes to several hours, use of contrast dye
left lateral decubitus/prone (may change during procedure)

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27
Q

A Nissen fundoplication is

A

when the fundus is wrapped around lower esophagus and sutured to reinforce lower esophageal sphincter
can be laparoscopic or transthoracic (open) approach
surgical time: 3-4 hours

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28
Q

Considerations for a Nissen fundoplication include

A

54-60 French esophageal dilator (Bougie), NG tube 12-24 hours postop, pneumatic compression stockings, smooth extubation

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29
Q

Medications that should be given for Nissen fundoplication include

A

H2 blockers, metoclopramide (2-4 hours preop), antibiotic, and antiemetics

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30
Q

Nissen fundoplication are performed via

A

GETA
induction include: position, RSI w/ cricoid pressure
lithotomy and reverse Trendelenburg positioning

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31
Q

Indications for esophagectomy include

A

ETOH, tobacco, chemo/radiation

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32
Q

Anesthetic considerations for esophagectomy are

A

surgical approach, invasive monitors, double-lumen tube, & postop pain management

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33
Q

An esophagectomy is when

A

the majority of thoracic esophagus and nearby lymph nodes are removed, stomach is moved up and attached to the remaining portion of the esophagus

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34
Q

The surgical approach for an esophagectomy includes

A

RSI b/c the esophagus is being removed
depends on patient condition, portion to be removed, surgeon skill/preference
Pt’s should be given gastrokinetics such as Reglan & avoid over-sedation preoperatively
Very sick patients- malnourished, pulm complications, wheezing, dyspnea

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35
Q

Complications of esophagectomy include

A

vocal cord paralysis, vocal cord palsy, wound infection, risk for fire

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36
Q

Gastrostomy is indicated for

A

dysphagia, high risk or active aspiration

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37
Q

Gastrostomy is when

A

an opening is created through the skin and the stomach wall to provide nutritional support or GI compression

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38
Q

The approach & anesthesia type for a gastrostomy is

A

laparoscopic, percutaneous (PEG) or open
surgical time < 1 hour
Anesthesia type: GA (RSI) or LA + sedation

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39
Q

A total gastrectomy is performed for

A

lesions in the upper 1/3rd of the stomach

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40
Q

A partial gastrectomy is performed for lesions in

A

the lower 2/3rd of the stomach

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41
Q

Anesthetic considerations for gastrectomy include

A 
stable or acutely ill/malnourished
correct hypovolemia & anemia
chemo/radiation
cross matched blood available
full stomach/NGT
invasive monitoring
warming
Extubate- needs to be smooth (fully awake)
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42
Q

Complications of gastrectomy include

A

hemorrhage, peritonitis, PE, pneumothorax, anticipate fluid shifts

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43
Q

Intestinal surgery is performed for

A

diverticulitis, cancer, Crohn’s disease, and ulcerative colitis

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44
Q

Intestinal surgery includes

A

small bowel resection, colectomy, colonoscopy

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45
Q

For patient’s undergoing intestinal surgery, they will have a

A

bowel prep and might be dry, hypovolemic, & have electrolyte disturbances

46
Q

Indications for a small bowel resection include

A

obstruction, cancer, diverticulum, Crohn’s disease

47
Q

A small bowel resection is when

A

healthy bowel is anastomosed or ileostomy created

48
Q

Small bowel resection considerations

A

bowel prep (hypokalemia, hypovolemia), surgical time: 2-4 hours, EBL <500 mL, preop EKG, CBC, electrolytes, T&S

49
Q

Postoperative complications for small bowel resection include

A

pulmonary effusion, anastomotic leak, short bowel syndrome, sepsis, small bowel necrosis

50
Q

Anesthetic considerations for small bowel obstruction include

A

aspiration precautions, RSI with cricoid pressure if obstruction is present, NG tube, foley catheter, avoid metoclopramide, consider epidural for postop pain management, large third space fluid loss (10-15 mL/kg/hr), hypothermia

51
Q

A colectomy is the

A

removal of part/all of the colon

can be open or laparoscopic

52
Q

Considerations with colectomy include

A 
bowel preparation 
clear liquids 1 to 2 days preoperatively
volume & electrolyte depleted
preoperative electrolytes 
IV/PO antibiotics Preop 
thoracic epidural for postop pain
corticosteroid supplements
53
Q

The liver is highly vascular and total blood flow is

A

1.5 L/min
80% blood flow supplied by portal vein
20% hepatic artery

54
Q

The liver is the only organ

A

capable of regenerating functional parenchyma within 24 hours of resection
-70% total liver mass can be regenerated in animal models

55
Q

The liver has

A

metabolic and hematologic roles

four lobes: left, right, quadrate, caudate or eight segments

56
Q

Preop H&P for liver resection includes

A

bruising, anorexia or weight changes, N/V or pain with fatty meals, pruritus or fatigue, abdominal distension/ascites, GI bleeding, scleral icterus, hepatomegaly or splenomegaly, palmar erythema, gynecomastia, asterixis, spider angiomata, petechiae, & ecchymosis

57
Q

Preop workup for a liver resection includes

A

CT or MRI for tumor location, 12-lead EKG/echocardiogram, CXR
lab studies: CBC, PT/PTT/bleeding time, chemistry profile, LFTs

58
Q

Optimization of the liver resection patient includes

A

correction of ETOH dependency, coagulopathy, pH, electrolyte abnormalities (esp K+), malnutrition, anemia, esophageal varices, & hepatic encephalopathy

59
Q

For patients undergoing liver resection, we assume

A

full stomach (ascites, decreased gastric & intestinal motility)- H-2 receptor blocker, metoclopramide, sodium citrate

60
Q

In regards to sedative pre-medication for the liver resection patient,

A

titrate to effect, altered pharmacodynamics or pharmacokinetics

61
Q

In regards to PT or INR & platelets for the liver resection platelet,

A

consider platelet infusion if <100,000 cells/microliter

PT or INR- parental Vitamin K, recombinant factor VII (FFP in emergency)

62
Q

Monitoring for patients with liver resections include

A

base decisions of severity of liver disease and type of surgery
2 LARGE BORE IVS- all but the most minor procedures b/c blood loss is unpredictable
A-line- BP & lab data
TEG to guide blood product administration
Foley catheter
OGT/NGT- be careful
TEE? (risky)
+/- CVP or PA (if pHTN)-multiple complex hemodynamic abnormalities

63
Q

CVP or PA can be used in liver resections to assess

A

hypovolemia, abdominal compartment syndrome, distributive shock, CHF

64
Q

For liver resection patients, benzodiazepines have

A

increased cerebral uptake
decreased clearance
prolonged half-life

65
Q

For liver resection patients, dexmedetomidine has

A

decreased clearance and prolonged half-life

66
Q

For liver resection patients, propofol has

A

longer recovery times after infusions
drug of choice with encephalopathy
single dose= similar response as normal patients

67
Q

For liver resection patients, etomidate, ketamine, and methohexital have

A

unchanged elimination half-life in most studies

68
Q

Intraoperative management of the liver resection patient includes

A

GETA- RSI or awake intubation- sevoflurane/isoflurane are agents of choice
fluids- no evidence colloids are better than crystalloids for resuscitation
altered pharmacokinetics
consider epidural for postop pain control
local/MAC- adequate sedation is essential to minimize SNS stimulation & resultant decreases in hepatic flow & O2 delivery- titrate carefully

69
Q

NMB and liver disease causes

A

increased volume of distribution that may require a higher initial dose
cirrhosis/advanced liver disease prolongs elimination of vec, roc, panc, and mivacurium= increased DOA
cisatricurium & atricurium are not dependent on hepatic elimination and can be used without adjustment

70
Q

Succinylcholine & liver disease

A

decreased cholinesterase levels,

succinylcholine effects may be prolonged

71
Q

Morphine & liver disease

A

prolonged half-life, exaggerated sedative & respiratory-depressant effects

72
Q

Meperidine & liver disease

A

may experience neuro-toxicity from accumulation of normeperidine

73
Q

Fentanyl and liver disease

A

plasma clearance is decreased- exaggerated effects

74
Q

Remifentanil & liver disease

A

elimination unaltered

75
Q

Alfentanil & liver disease

A

elimination half-life doubled–> enhanced effects

76
Q

Intraoperative fluid management for the liver patient includes

A

limiting fluid pre-resection–> CVP < 5 cmH2O increases risk of venous air embolism
Portal triad clamping
post-resection- restore to euvolemia
volume loading–> distension of vessels with difficulty controlling blood loss

77
Q

Patients with biliary obstruction are

A

particularly intolerant of blood loss

78
Q

For hypotensive liver patients, consider

A

increased doses or addition of non adrenergic vasoconstrictor (vasopressin) to support BP

79
Q

For patients with liver disease, there is an impaired ability to translocate

A

blood from pulmonary and splanchnic blood reservoirs to systemic circulation

80
Q

For liver disease patients, there is a decreased response to catecholamines because

A

of circulating vasodilators such as bile acids & glucagon

81
Q

Intraoperative complications of liver resection include

A 
hemorrhage, coagulopathy
hypocalcemia
hypoglycemia
VAE
pulmonary disturbances
82
Q

Post-operative complications of liver resection include

A

bleeding, bile leak, portal vein/hepatic artery thrombosis, liver failure

83
Q

The spleen is part of the

A

lymphatic system
filters foreign substances from the blood and removes blood cells
regulates blood flow to the liver and sometimes stores blood cells (sequestration)- healthy adults 30% of platelets are sequestered in the spleen

84
Q

The spleen is a highly

A

vascular organ of 300mL/min

85
Q

Preop anesthetic considerations for splenectomy include

A

evaluate underlying disease process and implications

chemotherapy & ITP

86
Q

Intraoperative anesthetic considerations for splenectomy include

A

asepsis, large-bore venous access, warming measures, epidural for post-op pain

87
Q

Complications of splenectomy include

A

atelectasis, pneumothorax, infection, hemorrhage & VAE

88
Q

Splenectomy is the only treatment for

A

hereditary spherocystosis and cancers of spleen
other indications for removal: trauma, abscesses, idiopathic thrombocytopenic purpura, Hodgkin’s staging, splenic artery rupture (pregnancy)

89
Q

Bariatric surgery is reserved for patients with

A

BMI >40 kg/m2

BMI >35 kg/m2 with related comorbidities not well controlled by medical therapy

90
Q

The greatest cause of perioperative 30 day mortality for bariatric surgery is

A

pulmonary emobli

91
Q

Bariatric surgery is a

A

surgical alteration of the small intestine or stomach to promote weight loss

92
Q

Bariatric surgery types include

A

malabsorptive procedures: jejuno-ileal bypass and biliopancreatic diversion
restrictive procedures: gastroplasty (VBG) and adjustable gastric banding (AGB)
combined restrictive and minimal malabsorptive Roux-en-Y gastric bypass

93
Q

Advantages to laparoscopic bariatric surgery include

A

less postop pain, lower morbidity, faster recovery, less fluid 3rd spacing, decreased wound infection, and smaller incisions

94
Q

Disadvantages to laparoscopic bariatric surgery include

A

complete NMB is important, positioning requirements increase fall risk, high risk for right main-stem intubation (d/t diaphragmatic shift), incidence of rhabdomyolysis in obese pts higher compared with open procedure

95
Q

For patients undergoing laparoscopic bariatric surgery, the anesthetists may need to

A

facilitate the proper placement of an intragastric balloon
prior to gastric diversion, ensure all endogastric devices are removed (avoid stapling in place or transection)
after gastric pouch in place, avoid blind NG insertion

96
Q

Preoperative considerations of the obese patient include

A

DVT prophylaxis–> encourage early ambulation
airway assessment= neck circumference most important factor
OSA/OHS increase risk difficult airway- consider preop ABG
IM injections unreliable- thickness overlying adipose tissue
pre-medications- anxiolysis and aspiration pneumonitis precautions

97
Q

Anesthetic considerations for the implantable gastric stimulator include

A

avoid N& V
valsalva may dislodge electrodes
ECG interference

98
Q

Implantable gastric stimulator is supposed to

A

make patient feel less hungry
stimulate gastric smooth muscle, decrease peristalsis
SQ electric pulse generator implanted on abdominal wall
2 lead electrodes on greater curvature of stomach

99
Q

Monitoring considerations of the obese patient include

A

monitors- appropriate sized BP cuff (forearm measurements overestimates BP)
IV & arterial line access may be challenging
Consider CVP or PAP catheter- significant CV or pulm disease or when large fluid shifts are expected

100
Q

Positioning considerations of the obese patient include

A

Regular OR table max weight~~200 kg
high incidence of pressure sores and nerve injuries
“stacking” or “ramped” position for intubation to align ear with sternum

101
Q

The most important induction consideration for the obese patient is

A

pre-oxygenation= most important step

-decreased FRC, increased O2 consumption, +/- higher incidence of difficult airway

102
Q

Induction considerations for the obese patient includes

A

induction drug dosing altered, consider awake intubation with minimal sedative-hypnotics, RSI?, may need two person mask ventilation/extra help, breath sounds may be difficult to auscultate, PEEP can be helpful intraop, routine use of reverse trendelenburg

103
Q

Prevention of thromboembolism for the obese patient includes

A

LMW heparin- limits postop pain management options
preop aspirin & warfarin to INR 2.3
Decreased the risk via preoperative exercise, antithrombotic drugs, stocking prophylaxis, nonpolycythemic Hct, increased CO, early ambulation

104
Q

The intraoperative fluid balance for obese patients takes into consideration that

A

they experience greater blood loss compared with non-obese patients secondary to technical difficulties/need for extensive dissection

105
Q

For obese patients, there is a risk of

A

acute tubular necrosis with inadequate fluid replacement in bariatric surgery

106
Q

There is a decreased ability to compensate for blood loss in obese patients and thus,

A

there is early threshold for replacement with colloids/blood products

107
Q

For placement of regional anesthesia in obese patients, ____ & _____ has been used

A

ultrasound & fluoroscopy

108
Q

Local anesthetic doses in the obese patient are

A

reduced by 20-25% due to epidural vascular engorgement and decreased epidural space

109
Q

The subarachnoid block height in obese patients can be

A

unpredictable- high spinal is possible

110
Q

For regional anesthesia in obese patients,

A

avoidance of intubation challenges vs. technically challenging landmark ID should be weight
central neuraxial blockade easier in lumbar region
longer needles may be required

111
Q

Postop pain management for the obese patient includes

A

epidural anesthesia
PCA with opioid (multi-modal w/ opioid sparing should be attempted)
LA infiltration of incisicion site
non-opioid analgesics/adjuvants
obesity risk factor for postop hypoxemia- consider monitored bed/ICU+ CPAP postop, semi-recumbent position for first 48-72 hours

931: Advanced Principles of Anesthesia I (22 decks)

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