Week 1 Abdominal General Surgery Flashcards
1
Q
Name the surgical areas that embody General Surgery
A
Esophagus Stomach Intestine/Colon Liver Gallbladder Pancreas Thyroid Skin Hernias Breasts
2
Q
Common GI Associated Problems (8)
A
Fluid and Electrolytes Anemia Cancer Obesity GERD Pain N/V Ascites
3
Q
Three techniques for General Surgery
A
General Anesthesia
Regional Anesthesia
MAC/IV Sedation
4
Q
Advantages of General Anesthesia
A
allows paralysis
more safely allows positioning extremes
more reliable
lower failure rate
5
Q
Disadvantages of General Anesthesia
A
increased stress response
known full stomach (aspiration risk)
more postoperative nausea and sedation
6
Q
Advantages of Regional Anesthesia
A
requires lower insufflation pressures, patient breathes spontaneously, decreased stress response, faster recovery period
7
Q
Disadvantages of Regional Anesthesia
A
Occasional failure, sympathectomy
8
Q
Describe MAC/Intravenous sedation
A
combined with local anesthesia
Patient breaths spontaneously
patient comfort levels
9
Q
Considerations for Anesthetic Management of General Surgery (10)
A
choice of anesthetic routine monitors foley catheter cuffed ET pneumoperitoneum evacuation of gastric contents positioning smooth emergence/ extubation anti-emetics pain management
10
Q
What is laparoscopic surgery used for?
A
diagnostic and surgical intervention
Minimally invasive
11
Q
What do they insufflate the abdomen with?
A
CO2
12
Q
Describe the view of laparoscopic and how
A
views abdominal contents through small incisions via small instruments through trocars
Camera will project image on monitor screen
13
Q
Types of Laparoscopic Surgery (7)
A
gastric colonic splenic hepatic gallbladder gynecologic urologic
14
Q
What are the advantages to laparoscopic surgery compared to open surgery? (7)
A
lower pain scores and opioid requirement
earlier ambulation and return to normal activities
lower incidence of post-operative ileus
usually faster recovery, shorter hospital stays
reduced post-operative pulmonary/diaphragmatic dysfunction: quicker return to preop pulm function
less stress response & less wound complications
lower cost (usually)
15
Q
What are the disadvantages of laparoscopic technique? (8)
A
impaired visualization expensive equipment requires specific surgical skill limited range of motion altered depth perception no tactile sensation increased PONV referred pain
16
Q
What are the relative contraindications of laparoscopic surgery? (6)
A
increased ICP severe CV disease severe respiratory disease dense adhesions Bi-directional V/P shunt or peritoneojugular shunt hypovolemia
17
Q
What are the two entry methods of entering laparoscopically?
A
closed technique and/or open technique
18
Q
Describe the closed technique
A
involves the spring-loaded needle known as the veress needle to pierce the abdominal wall at its thinnest point
then insufflation occurs
the trocar is blindly inserted or under direct vision to allow surgeon to pass instruments into abdominal cavity
19
Q
Describe the open technique
A
development of a 1-2.5mm midline vertical incision that begins at the lower border of the umbilicus and extends through the subcutaneous tissue and underlying fascia
Once surgeon in abdominal cavity, trocar can be placed by direct site and sutured in place. Gas then is insufflated into the side port of the hasson trocar
20
Q
Three types of gas that can be utilized for pneumoperitoneum
A
carbon dioxide
inert gases
gasless laparoscopy
21
Q
Why is CO2 mostly chosen for pneumoperitoneum?
A
more soluble in blood then air, helium, oxygen or nitrous oxide
easily absorbed by the tissues (high blood solubility) with rapid elimination
eliminated through respiration
non-combustible
colorless, odorless, inexpensive
22
Q
What the cardiovascular effects of CO2 insufflation?
A
HTN and Tachycardia from sympathetic stimulation
Hypotension from impaired venous return
Arrhythmia, bradycardia from vagal stimulation
23
Q
What are the respiratory effect of CO2 insufflation?
A
decreased FRC, compliance, increased ventilatory pressures, barotrauma, atelesctasis
24
Q
What are the renal effects of CO2 insufflation?
A
reduced renal perfusion
activation of RAAS, increased anti-diuretic hormone
25
What are the abdominal/gastric effects of CO2 insufflation?
increased intra-abdominal pressures, increased risk of gastric regurgitation, splanchic ischemia, carbon dioxide embolus, extra-peritoneal spread of carbon dioxide
26
What is physiologically increased in pneumoperitoneum? (11)
```
PaCO2
ETCO2
PAP (peak airway pressure)
MAP (mean arterial pressure)
SVR (systemic vascular resistance)
HR
CVP
IAP
ICP
Vd
Risk of regurgitation and aspiration
```
27
What is physiologically decreased with pneumoperitoneum? (7)
```
Cardiopulmonary function
Cardiac output
Venous Return
Functional residual capacity
vital capacity
renal function
```
28
How do you clinically manage pulmonary physiologic changes with pneumoperiteneum?
Position changes (decrease degree of trendelenberg)
Modify ventilator settings (pressure control)
Use PEEP with caution
Consider increasing volatile
Consider bronchodilators
29
How do you clinically manage cardiac physiologic changes with pneumoperiteneum?
slow, gradual abdominal insufflations
vent abdomen if IAP > 20mmHg
Evaluate intravascular volume (consider IVF bolus)
Consider treatment for pre-existing cardiac dysfunction
30
How do you clinically manage renal/hepatic physiologic changes with pneumoperiteneum?
Closely monitor hourly UOP
Administer IVF boluses
Consider diuretics
Maintain IAP <15mmHg
31
How do you clinically manage cerebral blood flow changes with pneumoperiteneum?
decrease degree of trendelenberg (adjust head up)
| vent abdomen if IAP > 20mmHg
32
Anesthesia Implications for Laparoscopic Surgery (Respiratory)
GA with cuffed ET tube for controlled ventilation
increased minute ventilation and positive inspiratory pressure often required
adjust respiratory rate, tidal volume and PEEP
33
Describe regional anesthesia and laparoscopic surgery
has been used
risky!
need to have a high block T4-T5 (SNS denervation) more difficult to compensate for CV, ventilatory changes, shoulder & distention pain completely alleviated
34
How do you avoid CV compromise in laparoscopic surgery?
avoid intra-abdominal pressure > 15mmHg
35
When do you need invasive monitoring with a laparoscopic case?
ASA 3-5 and/or abnormal gradient PaCO: ETCO2
| Allows for blood gas and BP measurements
36
What are the anesthesia implications for using an LMA during a laparoscopic procedure
spontaneous ventilation
lower incidence of sore throat
lower pain scores, less analgesic medications, less PONV
unable to administer muscle relaxation
37
Important Positioning TA's for Laparoscopic Surgery
prevent nerve injury
tilt not to exceed 15-20 degrees
make changes slowly
recheck ETT position after every position change
consider less aggressive fluid replacement in head down position
38
What are the common nerves damaged in laparoscopic surgery?
```
common peroneal nerve (lithotomy)
brachial plexus (shoulder braces, etc)
```
39
Anesthetic Considerations for the Maintenance phase of laparoscopic surgery
balanced techniques appropriately using volatile agent, opioids, or TIVA (no N2O)
consider TIVA if PONV
Continue muscle relaxation
Monitor hemodynamic and pulmonary status
Watch for endobronchial intubation during position changes
40
What are considerations when converting from laparoscopic to an open procedure
supine position
new fluid plan (3rd space losses will increase)
new pain management plan (opioid requirements will change)
new ventilator settings- may need to increase rate and tidal volume
41
Where can vascular intraoperative injuries can occur during an lapaproscopic procedure?
d/t trocar insertion/veress needle
| aorta, ICV, iliac vessels, cystic/ hepatic arteries, retroperitoneal hematoma
42
What cardiac intra-operative complications can occur during a lapaproscopic procedure
dysrhythmias, hybercarbia, increased vagal tone with peritoneal traction, BP changes
43
What are some intraoperative complications from laparoscopic surgery?
SQ emphysema
capnothorax, capnomediastinum, capnopericardium
CO2 embolism
44
How does capnothorax, capomediastinum, capnopericardium occur?
diaphragm defect, pleural tear, bullae rupture
| High degree of suspicion can be lifesaving
45
How does an CO2 embolism occur?
direct needle placement in vessel, gas insufflation into abdominal organ
46
Pathophysiology of a Gas Embolism
```
depends on size of bubbles and rate of entrainment
vapor lock in vena cava and right atrium
obstruction to venous return
acute RV HTN = paradoxical embolism
circulatory collapse
```
47
Diagnostic Tools for a Gas Embolism
```
pulse oximetry
esophogeal stethoscope- millwheel sound
sudden ETCO2 decrease
aspiration of gas from CVP
hypotension
bronchospasm
increased PIPs
```
48
Treatment of Gas Embolism
```
stop insufflation and desufflate
place into steep trendelenberg/ left lateral decubitus
discontinue N2O
administer 100% FiO2
hyperventilate
Place CVP
CPR
Consider CPB
```
49
Subcutaneous Emphysema
Accidental insufflation of extraperitoneum
be aware of increases in PaCO2 after plateau has been reached
not a contraindication for extubation
can track to thorax and mediastinum (capnothorax or capnomediastinum)
50
What are common laparoscopic GI procedures?
cholecystectomy
herniorrhapy
appendectomy
51
What is a cholecystectomy?
removal of a diseased gallbladder
| can be due to cholecystitis, cholelithiasis, cancer
52
What is herniorrhapy?
defect in muscles of the abdominal wall (inguinal, umbilical, incisional, abdominal, femoral, diaphragmatic)
53
What is the most common surgical procedure of the abdomen?
appendectomy
54
What causes the need for an appendectomy?
obstruction with inflammation by lymphoid tissue or fecal matter
55
Risk factors of converting a cholecystectomy from lap to open (7)
```
acute cholecystitis with thickened gallbladder wall
previous upper abdominal surgery
male gender
advanced age
obesity
bleeding
bile duct injury
```
56
How is a cholecystectomy performed?
laparoscopic or open
57
Potential complications of a cholecystectomy
bleeding from cystic artery and cystic liver laceration
| pnemothorax
58
Pre and Post-Operative Cholecystectomy considerations
Preoperative antibiotics controversial
| DVT prophylaxis
59
How is a patient positioned for a cholecystectomy?
surgeon on patients left (supine) or between patient's legs (lithotomy)
reverse trendelenberg, left tilt/right side up
60
What are symptoms of a spasm of the sphincter of Oddi?
recurrent attacks of upper right quadrant or epigastric abdominal pain
Non-colicky and steady pain
can be aggravated by foods, especially fatty foods
61
What can treat a sphincter of oddi spasm?
glucagon
62
Herniorrhapy Anesthetic considerations
outpatient, elective surgery
open or laparoscopic
potential for incarceration if not reduced
avoid strain
general, local, or regional (TB) anesthesia
63
What is an incarcerated hernia?
part of the intestine or abdominal tissue that becomes trapped in the sac of a hernia
They can cause intestinal obstruction or strangulation and infarction, resulting in a high incidence of infection, hernia recurrence and operative mortality esp in older patients
URGENT SURGERY
64
What is an strangulated hernia?
```
emergency surgery (requires general anesthesia) can lead to necrotic bowel requiring bowel resection
higher morbidity and mortality
```
65
Can a patient cough after a herniorrhapy?
discuss with surgeon
66
What is the EBL of herniorrhapy?
about 50ml
67
What happens if an appendectomy perforates?
septic shock
| peritonitis
68
What are some anesthetic implications of an appendectomy?
```
fluid and electrolyte deficits
aspiration precautions
antibiotics
avoid reglan with obstruction
skeletal muscle relaxant
```
69
Where is pain detected after a laparoscopic procedure?
procedures are associated with intra-abdominal, incisional, and shoulder pain (d/t irritation of diaphragm, and/or visceral pain from biliary spasms)
70
What are a good post operative pharmacological pain managements?
```
opioids
NSAIDs
acetaminophen
dexamethasone
local anesthetic infiltration (incisional and intraperitoneal)
```
71
What are the three parts of a robotic laparoscopic technique?
control console
patient side card (robotic arms)
equipment tower (screens)
72
Advantages of Robotic Laparoscopy
```
3 dimensional view
depth perception
intutitive movements
increased precision 10-15x magnification
increased free movement
```
73
Disadvantages of Robotic Laparoscopy
```
Massive system
limited working space
limited patient access
limited instrument availability
maintenance cost
```
74
Preparation for robotic surgery includes:
```
2 peripheral IVs
consider arterial line
limit IVF initially
trendelenburg/lateral/flexion
Limited patient access
Padding
```
75
Types of GI Lab Diagnostic Tests include
esophagogastroduodenoscopy
endoscopic retrograde cholangiopancreatography
colonoscopy
76
What is a endoscopic retrograde cholangiopancreatography
procedure that combines upper gastrointestinal (GI) endoscopy and x-rays to treat problems of the bile and pancreatic ducts
used to diagnose and treat pancreatic and biliary disorders
contrast dye used
77
What is the purpose of an EGD/Colonoscopy?
diagnostic/therapeutic
| minimally invasive
78
How can a EGD/Colonoscopy be performed?
conscious sedation, topical/ general anesthesia
79
Considerations for an EGD include
sharing the airway/ limited access
mouth piece inserted by endoscopist to prevent biting on scope
supplemental oxygen
may consider GETA if obese
80
What are the potential complications of EGD/colonoscopy?
perforation
bleeding
desaturation/laryngospasm
81
What is the purpose of a colonoscopy?
views lining of rectum and colon
cancer screening
treatment of polyps
82
What are potential complications of a colonoscopy?
perforation
bleeding
desaturation/laryngospasm
83
Anesthetic considerations for Colonoscopy?
colon prep, clear liquid diet
left lateral decubitus
usually heavy sedation or general
84
Describe the ERCP procedure
left lateral or prone; positioned changed during procedure
| length 30 minutes- several hours
85
Complications of ERCP
perforation
bleeding
laryngospasm
desaturation
86
Indications for esophageal surgery
GERD
Cancer
Histal Hernia
Motility disorders
87
Patient symptoms for Esophageal surgery
dysphagia
heartburn
hoarse voice
chest pain
88
What a nissen fundoplication?
can be performed laparoscopically or open (transthoracic)
3-4 hours
fundus is wrapped around lower esophagus and sutured to reinforce lower esophageal sphincter
89
Describe the anesthesia plan for a nissen fundoplication
GETA (cuffed tube)
position, rapid sequence cricoid pressure for induction
H2 blockers, reglan, antibiotics, antiemetics
Position includes: lithotomy and reverse trendelenburg
Needs a smooth extubation
90
What is an esophagectomy?
when majority of the thoracic esophagus and nearby lymph nodes are removed
stomach is moved up and attahed to the remaining portion of the esophagus
91
Why would a patient need a esophagectomy?
tobacco/ETOH
| concomitant chemo/radiation
92
Anesthetic considerations for Esophagectomy
surgical approach
invasive monitors
double lumen tube
post-op pain management
93
What does the surgical approach of an esophagectomy depend on?
patient condition, portion to be removed and surgeon skill/ preference
94
What is a gastrostomy?
creates an opening through the skin and the stomach wall to provide nutritioinal support or GI decrompression
95
Indications for gastrostomy?
dysphagia, high risk or active aspiration
96
How is a gastrostomy performed?
laparoscopic, percutaneous (PEG) or open
97
What is the surgical time for a gastrostomy?
less then 1 hour
98
What anesthesia can be used for a gastrostomy?
general anesthesia (rapid sequence induction) or local anesthesia and sedation
99
What is a gastrectomy?
partial or total removal of stomach
100
Indications for a gastrectomy?
peptic ulcers, gastric perforation, cancer, benign tumors/ polyps
101
What do you have to watch for post-gastrectomy?
gastric dumping syndrome, vitamin B12 deficiency, iron deficiency anemia and poor calcium absorption
102
Anesthetic considerations for abdominal surgery
```
stable or acutely ill/malnourished
correct hypovolemia & anemia
chemo/radiation
cross matched blood available
full stomach/NGT
invasive monitoring
warming
extubate?
```
103
What organs include intestinal surgery?
small bowel resection, colectomy, colonscopy
104
Indications for intestinal surgery include:
diverticulitis
cancer
crohn's disease
ulcerative colitis
105
Considerations for Intestinal surgery include:
bowel preparation
| postoperative colostomy, ileostomy
106
Indications for a small bowel resection
obstruction
cancer
diverticulum, crohn's disease
107
Surgical time for a small bowel resection
2-4 hours
108
EBL for small bowel resection
< 500ml
109
Pre-operative considerations for small bowel resection
```
bowel prep (hypokalemia, hypovolemia)
Pre-op EKG, CBC, electrolytes, type and screen
```
110
Small Bowel Anesthetic considerations
```
aspiration precautions
RSI with cricoid pressure
NGT & Foley
NO REGLAN
consider epidural for post op pain
large third space fluid loss (10-15ml/hr)
hypothermia
```
111
Post-operative Complications for Small bowel resection include
pulmonary effusion, anastomotic leak, short bowel syndrome, sepsis, small bowel necrosis
112
Colectomy is
removing all or part of the colon
113
Colectomy can be performed
open or laparoscopic
114
Pre-op for Colectomy
bowel preparation
clear liquids 1-2 days prior
volume and electrolyte depleted
IV and oral antibiotics
115
Post-operative pain for colectomies can have
thoracic epidural
116
What are the four lobes of the liver?
left right quadrate and caudate
117
What is the role of the liver?
metabolic and hematologic roles
118
Name characteristics of the liver
eight segments
only organ capable of regenerating functional parenchyma within 24 hours of resection
highly vascular about 1.5:/min
119
Where does majority of deoxygenated blood from the liver empty into?
portal vein 80%
120
What supplies the liver with oxygenated blood?
20%
| hepatic artery
121
For a liver resection, what do history do you want to ask pre-operatively?
```
bruising
GI bleeding
palmary erythema
spider angiomata, petechiae ecchymosis
anorexia or weight changes
N/V or pain with fatty meals
abdominal distention/ ascites
hepatomegaly or splenomgealy
scleral icterus
gynecomsatia
asterixis
pruritus or fatigue
```
122
What do you include in the pre-op workup for a liver resection?
CT or MRI of tumor location
12-lead EKG/echocardiogram
CXR
CBC, PT/PTT, bleeding time, chemistry profile, LFTs
123
Monitoring for Liver Resection
```
large bore IVs
A-line for BP and laboratory data
May or may not have CVP or PA (if pulm HTN)
TEG
Foley
OGT/NGT
TEE?
```
124
How do you optimize our liver resection patient pre-operatively?
correction of ETOH dependency, coagulopathy, pH, electrolyte abnormalities, malnutrition, anemia, esophageal varices and hepatic encephalopathy
consider platelet infusion if < 100,000 cells/microliter
assume full stomach (h2 receptor blocker, metoclopromide, sodium citrate)
125
PT or INR considerations for liver resection
parental vitamin K, recombinant factor VIII (FFP in emergency)
126
Anesthetic Management in Liver Resection
Local/MAC adequate sedation is essential to minimize SNS stimulation and resultant decrease in hepatic blood flow and O2 delivery- titrate carefully
GETA: RSI or awake intubation
Iso and Sevo agents of choice
Altered pharmacokinetics
Controversial epidural placement for post-op pain
127
Benzodiazepines in Liver Resection Cases
increased cerebral uptake
decreased clearance
prolonged E1/2 life
128
Dexmedetomidine in Liver Resection Cases
decreased clearance and prolonged 1/2 life
129
Propofol in Liver Resection Cases
single dose similar response as normal patients, recovery times may be longer after infusions
130
what is the drug of choice in patients with encephalopathy?
propofol
131
What drugs are unchanged in most studies during a liver resection?
TPL, etomidate, ketamine, methohexital
132
Morphine and Liver Disease
prolonged E1/2 life
increased bioavailibity of oral form
decreased plasma protein binding and exaggerated sedative and respiratory depressant effects
133
Meperidine and Liver Disease
50% reduction in clearance and a doubling of the half-life
| may experience neuro-toxicity from accumulation of normeperdine
134
Fentanyl and Liver Diseaes
plasma clearance is decreased
| continous infusions or repeated dosing in cirrhotic patients may produce more exaggerated and pronounced of effect
135
Sufentanil and Liver Disease
pharmacokinetics are not significantly altered
some differences seen in E1/2
so infusions are multiple doses could cause prolonged effect
136
Alfentanil and Liver Disease
E1/2 Life almost doubled and higher free fractions of the drug are observed, which can lead to a prolonged duration of action and enhanced effects
137
Remifentanil and Liver Disease
Elimination unaltered
138
NMB and Liver Disease
increase volume of distribution may require a higher initial dose
139
Cirrhosis/Advanced liver disease reduces elimination of whatNMB?
vec, roc, pan and mivacurium
| increased DOA, especially with repeated doses or infusions
140
What NMB are not dependent on hepatic elimination?
Atracurium and cisatracurium
141
What NMB may have a prolonged effect?
Succinylcholine
| d/t decreased plasma cholinesterase levels
142
How is sugammadex excreted?
unchanged in urine
143
Catecholamines in Liver Disease
decreased because of circulating vasodilators including bile acids and glucagon
Impaired ability to translocate blood from pulmonary and splanchic blood reservoirs to systemic circulation
consider increased doses or addition of non-adrenergic vasoconstrictor (vasopressin) to support BP
144
What patients are particularly intolerant of blood loss?
biliary obstruction
145
Intra-operative fluid management of Liver Resection
volume loading can lead to distention of vessels with difficulty controlling blood loss
limiting fluid pre-resection will lead to a CVP less then 5cmH20
portal triad clamping
post resection restore euvolemia
146
Intraoperative Potential Complications of Liver Resection
```
hemorrhage
coagulopathy
hypocalcemia
hypoglycemia
VAE
pulmonary disturbances
```
147
Post-operative Potential Complications of Liver Resection
bleeding
bile leak
portal vein/ hepatic artery thrombosis
liver failure
148
Characteristics of the Spleen
upper left abdomen, just inside the rib cage (9-11th ribs)
part of the lympatic system
filters foreign substances from the blood and removes blood cells
regulates blood flow to the liver and sometimes stores blood cells (sequestration)
highly vascular organ
149
Indications for splenectomy
```
only treatment for hereditary spheroctosis an cancers of spleen
trauma
abscesses
idiopathic thrombocytopenia purpura
hodgkin's staging
```
150
Complication of Splenectomy
splenic artery rupture (pregnancy)
151
pre-operative anesthetic implications for Splenectomy
```
underlying disease process and implications
chemotherapy
ITP
CBC platelets PT PTT
type and cross
```
152
intraoperative anesthetic implications for Splenectomy
asepsis
large bore venous access
warming measures
epidural for post op pain
153
Complications of a splenectomy
```
Atelectasis
pneumothorax
infection
hemorrhage
VAE
```
