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931: Advanced Principles of Anesthesia I > Urologic surgeries part 2 > Flashcards

Urologic surgeries part 2 Flashcards

1
Q

What are the common urologic procedures.

A

cystoscopy
extra-corporeal shock wave lithotripsy (ESWL)
transurethral resection of the prostate (TURP)
laparoscopic/robotic urologic procedure
open nephrectomy
renal transplant

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2
Q

Cystoscopy is when the

A

urologist uses a cystoscope to examine urethra & bladder

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3
Q

The anesthetic considerations for cystoscopy include

A

-local/MAC
-spinal anesthesia- offers relaxation with real-time patient assessment
general anesthesia- LMA vs. ETT
lithotomy
procedures can be very quick or last hours

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4
Q

ESWL is a

A

non-invasive treatment that uses high energy ultrasound waves to break up the calculi

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5
Q

______ is common in ESWL

A

hematuria

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6
Q

Describe the management of nephrolithiasis

A

affects 9% of the population

  • if calculi <5 mm in diameter, expected to pass without intervention
  • 5-10mm –> medical management
  • > 10 mm–> unlikely to pass spontaneously
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7
Q

For ESWL, it is typically performed

A

outpatient under general anesthesia
water immersion is not used today
ECG placement is important (R wave used to trigger shocks)

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8
Q

Describe contraindications to ESWL

A

active UTI
uncorrected bleeding disorder or coagulopathy
distal obstruction
pregnancy

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9
Q

Describe complications for ESWL

A
  • dose-dependent hemorrhagic lesions on kidneys
  • perforation, rupture or damage to colon, hepatic structures, lungs, spleen, pancreas, abdominal aorta, or iliac veins
  • HEMATURIA develops in most patients
  • diabetes, new onset HTN or decreased renal function
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10
Q

Anesthesia for ESWL can be performed under

A

MAC
GA- rapid onset, can control patient movement
Spinal/epidural (T4/T6 level)
Topical LA

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11
Q

Anesthesia considerations for ESWL include

A

laser eye protection
HCG-ionizing radiation can damage fetus
document negative urine culture
discontinue ASA, anticoagulants, platelet inhibitors, and NSAIDs 7-10 days prior to procedure

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12
Q

Percutaneous nephrolithotomy is a

A

procedure to remove kidney stones 25 mm or smaller

rigid scope is inserted in renal calyx under fluoroscopy

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13
Q

Percutaneous nephrolithotomy is performed under

A

GA and requires postoperative hospitalization

patient prone or supine

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14
Q

Complications of percutaneous nephrolithotomy includes

A

pain, fever, UTI, renal colic, septicemia, bleeding, pneumothorax, hemothorax, anaphylaxis

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15
Q

The most common surgical procedure performed in men over 60 is

A

TURP

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16
Q

_____ percent of men will require intervention for BPH

A

40%

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17
Q

__________ are used for medical management of BPH

A

alpha-blocking agents

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18
Q

Anesthetic risks with TURP are related to

A

patient age & associated comorbidities

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19
Q

Describe a TURP.

A

scope placed through urethra to cut away obstructing lobes of the prostrate
bladder distended and continuous irrigated is used

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20
Q

TURP is commonly performed via

A

general anesthesia

Spinal anesthesia is anesthetic of choice because signs and symptoms of complications are better detected

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21
Q

TURP syndrome is a

A

rare, but significant complication with mortality as high as 25%
large amounts of fluid absorbed through the prostate

22
Q

The hallmark symptoms of TURP syndrome are related to****

A

a combination of water intoxication, fluid overload & hyponatremia

23
Q

Describe what issues fluid overload can cause in TURP syndrome.

A

HTN, bradycardia, arrhythmia, angina, pulmonary edema, CHF, & hypotension

24
Q

Describe the issues that water intoxication can cause in TURP syndrome.

A

confusion, restlessness, seizure, lethargy, coma, dilated sluggish pupils

25
Q

Describe the issues that hyponatremia presents as in TURP syndrome.

A

CNS changes, widened QRS, T-wave inversion

26
Q

Describe the issues that glycine toxicity presents as in TURP syndrome.

A

N/V, headache, transient blindness, myocardial depression

27
Q

If you’re performing a spinal for a TURP, you must block up to

A

T10

28
Q

Irrigation solutions used for TURP syndrome include

A

distilled water, saline, cytal (sorbitol & mannitol), glycine

29
Q

Complications of TURP syndrome include

A

volume overload with pulmonary edema, dilutional hyponatremia with hypoosmolality, cardiac effects, renal toxicity (glycine), hyperglycemia, hypothermia

30
Q

Additional complications of TURP syndrome include

A

glycine absorption
bleeding- not common but difficult to assess due to irrigation
bladder perforation- not common; symptoms vary depending on whether intraperitoneal or extraperitoneal
infection
skin burns- greater incidence with monopolar cutting device, may also impact patients with pacemakers

31
Q

With TURP syndrome, fluid absorption is dependent upon**

A 
size of resection
duration of resection
irrigation solution pressure
number of venous sinuses open at one time
provider experience
32
Q

Up to _____ mL of fluid can be absorbed per minute

A

30 mL; up to 8L in two hours

33
Q

Uptake of 1L of irrigant can decrease serum Na+ by

A

5-8 mEq/L

serum Na+ <120 mEq/L associated with severe reactions

34
Q

Glycine is an amino acid that acts as an

A

inhibitory transmitter

35
Q

Excessive absorption of glycine can lead to

A

nausea & vomiting, fixed & dilated pupils, headache, weakness, muscle incoordination, TURP blindness, seizures, & hypotension

36
Q

Prevention of TURP includes

A

**avoid Trendelenburg position
limit resection to less than one hour
place irrigating solution less than 60 cm above prostate
monitor electrolytes
use a regional technique with light sedation

37
Q

Treatment of TURP syndrome includes

A

early recognition
correcting hyponatremia- 3-5% saline at no greater than 100 mL/hr, goal is Na >120 mEq/L, increase Na 0.5 mEq/hour or 8 mEq/day, rapid reversal can lead to demyelination syndrome
20 mg IV furosemide
labs/tests: Hct, electrolytes, creatinine, glucose, ABG, 12 lead ECG
IV midazolam 1 mg at a time for seizures
intubate for pulmonary edema
PRBCs if necessary
investigate for DIC or primary fibrinolysis

38
Q

Anesthetic concerns of laparoscopic urologic surgery include

A

pneumoperitoneum
alterations in renal & hepatic perfusion
Co2 absorption- potential for acidosis
extremes in patient position (increased intrabdominal & intrathoracic pressures)
hemorrhage
urologic system is retroperitoneal- communicates with thorax- risk for subcutaneous emphysema

39
Q

Two categories of robotic urologic assisted surgery include:

A

upper tract surgery- simple or radical nephrectomy, radical nephroureterectomy, nephron-sparing surgery
pelvic surgery: radical cystectomy, radical prostatectomy

40
Q

Positioning considerations for the robotic urologic surgery case include

A

steep Trendelenburg (+lithotomy for prostatectomy), arms tucked at sides
airway assessment before extubation
limit fluids until urethra is reconnected (2L total IVF)

41
Q

Duration & EBL of robotic urologic surgery includes

A

duration: 3-4 hours

EBL <300 mL

42
Q

Additional surgical considerations for robotic urologic surgery includes

A 
large bore PIV +/- arterial line
DVT prophylaxis
eye protection
OGT
Bair hugger
antibodies
dexamethasone
remifentanil infusion is common
43
Q

Nephrectomies can be performed

A

open or laparoscopic

44
Q

Anesthetic considerations for nephrectomy include

A 
lateral jack-knife position
cardiovascular compromise
third-spacing & edema
hemodynamic monitoring
postoperative pain management
45
Q

Renal transplant is the

A

mainstay treatment for ESRD

donors may be living or deceased

46
Q

The 5 year survival rate of renal transplant is

A

70%

47
Q

The most frequent solid organ transplanted today is

A

the kidney

48
Q

Describe the anesthetic considerations for the patient undergoing renal transplant.

A

GA- propofol (cisatricurium), arterial line, CVP monitoring, T&C, 18 G & central line, a-line, avoid neo & epi, give dopamine for renal blood flow, clamping Foley, give lasix & mannitol

49
Q

Patients undergoing renal transplant will be on

A

immunosuppressant therapy

50
Q

The transplanted kidney is placed

A

in the right or left extraperitoneal fossa (right side preferred)

51
Q

The transplanted kidney is attached via

A

vascular anastomoses of external iliac artery & vein & ureter anastomosed to bladder

931: Advanced Principles of Anesthesia I (22 decks)

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