Abdominal Procedures Flashcards
(99 cards)
1
Q
Vent management of laparotomy
A
- Low tidal volumes (6-8 mL/kg IBW)
- Monitor peak inspiratory pressures!
* High PIP may prevent abdominal closure - Plateau pressure <16 mmHg
- moderate PEEP, titrated to effect
- Recruitment maneuvers.
2
Q
lapatotomy IVF mangement under resusitation
A
hypovolemia
inadequate tissue perfusion
metabolic acidosis
organ dysfunction
3
Q
laparotomy IVF management over resuscitation
A
tissue edema
pulmonary edema
impaired oxygenation
anastomotic breakdown
4
Q
A
5
Q
visceral pain organ after laparotomy
A
Stretch & inflammation of the peritoneum
Resolves quicker than somatic pain
6
Q
somatic pain skeletal after laparotomy
A
Skin & muscle incision.
Interferes with deep breathing, coughing, mobilization, ambulation.
7
Q
5 effects of poorly controlled pain
Past c
A
Atelectasis
Pneumonia
Cardiac complications (ischemia)
Thromboembolic events
Stress response
(cortisol, IL, cytokine)
8
Q
Anesthesia
Considerations for
Laparotomy:
Multimodal Pain
Management
A
- Thoracic epidural
- TAP block t8-l1
Opioid & non-opioid analgesics
* Short & long-acting opioids
* Ketamine, lidocaine,
magnesium,
dexmedetomidine
* NSAIDs?
9
Q
Pneumoperitoneum Closed vs Open
A
closed (Veress needle)
open (Hasson trocar)
10
Q
benefits of CO2 for insufflation
A
increases work and view space
inexpensive
colorless
nonflammable
inexplosive
nontoxic
min risk of air embolism
11
Q
Drawbacks of CO2 insufflation
A
Hypercarbia
Respiratory acidosis
Irritation of peritoneum
Diaphragm (postop shoulder pain)
12
Q
Insufflation Pressure
A
should be less than <15mmHg
13
Q
Insufflation Pressure effect on CV system
A
Increased HR, SVR, MAP
caused by compression of vessels & release of vasopressin/renin
14
Q
Vagal-mediated bradycardia from peritoneal stretch during insufflation
A
release pneumoperitoneum
administer medications
(Glyco, atropine, ephedrine, epinephrine)
slow insufflation <16mmHg
15
Q
CO2 effect on QT
A
prolongs QT
16
Q
Respiratory effects of pneumoperitoneum
A
increases PIP, paco2, etco2
diaphragm cephalad
deceased FRC and FEV
decreased compliance
atelectasis
shunt
VQ mismatch
pulmonary vasoconstriction
17
Q
Offset effects of pneumoperitoneum
A
acidosis: increase minute ventilation by 20-30%
18
Q
Penumo Neuro Effects
A
CO2 = cerebral vasodilation
hypercarbia increases ICP & is exaggerated in trendelenburg
depressed consciousness PaCo2 >80mmHg
19
Q
Pneumo effect on hepatic and splanchnic
A
- Increased lipid & protein oxidative
substances - Elevated liver enzymes
- CO2 has vasodilatory effect on
splanchnic vessels
20
Q
Insufflation Pressure Effect on the Renal System
A
- Decrease UO and GFR
- Increase CC, sympathetic response, & renal vasoconstriction.
21
Q
Three hormones released during pneumoperitoneum
A
Release of ADH, renin, and aldosterone.
22
Q
Insufflation Pressure affects the respiratory system
A
- Increase ETCO2, PCO2, PIP, ITP
- Decreased arterial pH, VC, FRC, compliance = atelectesis, VQ mismatch, shunt.
- Diaphram cephalad
- Risk of endobronchial intubation from upward displacement of carina
- Pulmonary vasoconstriction.
- PCV > VCV to maintain PaCO2, lower peak and mean airway pressures, careful release of pneumoperi —> watch TV
23
Q
What to do when a patient has vagal-induced bradycardia from insufflation?
A
release pneumoperitoneium
administer glyco, atropine, epi, ephedrine
slow reinsufflation
<16mmHg
24
Q
cardiac conduction & pneumoperitoneum
A
prolongs QT –> vent instability
25
Position that relieves effects of pneumoperitoneum
reverse trendelenberg
26
increases effects of pneumoperitoneum
Trendelenburg position
20%-30% increase in MV needed to prevent respiratory acidosis
27
three ways to decrease the risk of vascular and viseral injury during laparoscopic procedure
1 Open (Hansson) entry
2 urinary cath w/ methylene blue
3 Placement of initial trocar under high pressure (25mmHg)
28
Gas embolism travels:
to right side of heart into pulmonary
circulation and lodge in pulmonary outflow tract
29
Gas embolism increases
Pulmonary Artery Pressure
RV failure
30
31
gas embolism decreases
* Decreased pulmonary venous return
* Decreased left ventricular preload
* Decreased cardiac output
* Asystole & cardiovascular collapse
32
diagnosing gas embolism
gold standard: TEE. (identifies as small of 0.02ml/kg)
Doppler sound changes & increased PAP at 0.5 mL/kg gas
"Classic mill wheel murmur" audible at 2 mL/kg gas
33
S/S gas embolism
Tachycardia
Hypotension
Dysrhythmias
Cyanosis/hypoxia
Chest pain/dyspnea
Increased PAP
Pin wheel murmur
pulmonary edema
wheezing/rales
decreased PETCo2, increase end tidal nitrogen
34
treatment of gas embolism
1 stop gas insufflation
2 discontinue nitrous oxide
3 100% oxygen
4 evaluate for pneumo
5 floor surgical field with normal saline
6 Left lateral decub
7 aspirate via CVC
8 supportive measure to maintain hemodynamics
35
treatment of sub q emphysema
1 Decrease intraabdominal pressure
2 Discontinue nitrous oxide
3 Place on 100% Fio,
4 Evaluate for a pneumothorax
5 Increase minute ventilation to treat hypercarbia
6 Evaluate ETCO, and Paco,
7 Assess chest wall and lung compliance
8 Assess airway to rule out compression prior to extubation
36
three things that cause increase risk of sub q emphysema
* ETCO2 > 50 mm Hg
* Operative time > 200 mins
* Greater than 5 entry points
37
Factors leading to sub q emphysema
insufflator ( high gas flow and high pressure)
intra-abdominal pressure >15
multiple attempts at abdominal entry
versus needle not placed in peritoneal cavity
skin around cannula isnt snug
>5 cannulas
laparoscope used a lever
cannula acting as a fulcrum
long arm of the laparoscope
tissue integrity/structural weakness compromised by repetitive movement
improper cannula placement
soft tissue dissection
gas dissection leading to move dissection
procedures >3.5 hours
ETCO2 >50
38
signs of sub q emphysema
Crepitus
Hypercarbia
Hypertension
Elevated ETCO2
Decreased lung compliance
Cardiac arrhythmias
39
spinal/epidural laparoscopic procedures
Associated with
* Reduction in stress response
* Early ambulation & reduced
incidence of DVT
* Effective postoperative analgesia
40
lap procedures and regional anesthesia
Higher sensory level may be required
* Patient discomfort
* Hypotension 2/2 sympathetic
blockade
* Compromised ventilation 2/2
cephalad pressure + sensory &
motor blockade
* Shoulder pain from diaphragmatic
irritation 2/2 CO2 insufflation
41
Laparoscopic Procedures: Regional
Anesthesia
1 decreased SVR
2 decreased RA filling
3 decreased stim of baroreceptors
4 decreased HR
42
Laparoscopic Procedures: General
Anesthesia
1 Cuffed ETT ideal (LMA controversial due to high pressures
2n MV increased 15-35% to offset CO2 absorption & maintain PETCO2 35-45 mm Hg
3 PCV vs VCV
4 PEEP of 10 + IPAP 40/40s --> improves compliance
43
LMA during Laparoscopy
* Use correct size of LMA.
* Use LMA that allows for gastric drainage (i.e., LMA ProSeal).
* Make surgeon aware of the use of LMA.
* Use total IV anesthetic technique or volatile agent.
* Use low-pressure insufflation.
* Avoid steep Trendelenburg position.
* Avoid inadequate anesthesia during surgery.
* Avoid disturbance of the patient during emergence.
44
Laparoscopic
Procedures: Pain
Management
Local anesthetics
Infiltration at surgical incisions
Intravenous infusions
Transversus abdominis plane (TAP)
block
* Blocks terminal branches of
lower intercostal nerves (T8-L1)
45
Robotic Surgery: Anesthesia
Considerations
significantly longer surgical time
POVL
spatial restrictions
restrictions on position changes
steep trendelenburg common
limited access to airway
46
CV Physiologic consequences of Deep Trendelenburg
Increased:
* Mean arterial Pressure (MAP)
* Central Venous Pressure (CVP)
* Pulmonary Capillary Wedge Pressure (PCP)
* Systemic Vascular Resistance (SVR)
Unchanged:
* Heart rate (HR)
* Stroke Volume (SV)
* Mixed Venous Oxygen Saturation
47
Respiratory Physiologic consequences of Deep Trendelenburg
Increased:
* Airway Resistance
* Peak pressure
* Plateau pressure
* End-tidal carbon dioxide (ECO,)
* Upper airway edema
Decreased
* Lung compliance
* Vital capacity (VC)
* Forced Expiratory Volume in 1 second (FEV1)
48
Cerebrovascular changes of Deep Trendelenburg
Increased:
* Intracranial pressure
* Hydrostatic pressure gradient
* Cerebral vascular resistance
Decreased:
* Cerebral venous drainage
Unchanged:
* Regional cerebral oxygenation
* Cerebral perfusion pressure
49
robotic surgery effect on urine output
Significantly decreases with pneumoperitoneum
Urinary retention & UTIs more
common with robotic surgery
50
Anterior ischemic optic neuropathy (AION)
* Occlusion or hypoperfusion of anterior optic nerve
* Most common after cardiac, major vascular, spine procedures
51
Posterior ischemic optic neuropathy (PION)
Infarction of optic nerve posterior to lamina cribrosa
* Usually result of elevated venous pressures, increased intraocular pressures, interstitial edema
compromising blood flow to eye
* Prone & steep T-burg positions
* Associated with anemia & hypoperfusion
52
AION & PION
present with sudden onset of painless visual loss & visual field deficits discovered after emergence from
anesthesia
53
POVL (central retinal artery occlusion) and robotic surgery
Central retinal artery occlusion
(CRAO) & cortical blindness
associated with procedures with high
likelihood of emboli, severe
hypotension, direct compression of
globe
54
risk factors for POVL
* Male
* Hypotension
* Prone & T-burg position
* Prolonged procedures
* Increased blood loss
* Decreased use of colloid
55
POVL prevention intraop
Reduce venous congestion &
interstitial edema in head
* Stage surgical procedures, reduce
operative time
* Keep head at or above level of
heart
* Include colloid in non-blood
replacement strategies (i.e.
Albumin)
* Topical beta blockers & carbonic
anhydrase inhibitors
56
Goal of ERAS fluid management
Goal = "zero" fluid balance at end of surgery
Basal infusion of isotonic crystalloid
solution (LR, etc)
* 3 ± 2 mL/kg/hour guided by objective
measures of hypovolemia
o HR, BP, UOP, CVP all unreliable
measures of volume status
* Avoid normal saline 0.9%
o Hyperchloremic metabolic acidosis
o Reductions in gastric blood flow & pH, changes in renal perfusion
57
ERAS Fasting Prolonged fasting
* Inhibits insulin secretion
* Causes release of catabolic
hormones (cortisol, glucagon)
* Promotes insulin resistance,
glycogen depletion, & protein
breakdown
* Hypovolemia from fasting can
result in large hemodynamic shifts
during induction of anesthesia
58
ERAS fasting recommendations
Avoid prolonged fasting
* Consume clear liquids up to 2
hours before anesthesia
o Lower gastric volumes vs
conventional fasting
guidelines
* Intentional carbohydrate loading
before surgery
o Gatorade night before & 2-3
hours prior to induction
59
Robotic Surgery: General
Considerations
- OG/NG to decompress
- foley for procedures >2hrs
- Access to lines and monitoring devices
-Two IV
- NIBP on each arm
- Eye and face protection
-Frequent position checks
-warming devices
-NMBD
-Bed locked
60
temporary cryoablation with nitous oxide
neg 22 degrees for mapping
61
permanent tissue destruction for EP nitrous oxide
neg 75 degrees
62
What arrhythmia is common with cryoablation
Iatrogenic AV block
63
What med must pt stop taking before EP lab
antiarrhythmic drug
don’t user lidocaine for induction --> propofol is good
INBKL
64
TIVA in EP lab
PA occlusion can stop uptake of volatiles
65
pacemaker indications
sick sinus syndrome
2nd-degree heart block
AV block --> TV pacing
3rd degree heart block
symptomatic bradycardia
66
ICD's
congential long QT
HCM
Brugada syndome
67
how many leads on an ICD
single ventricular lead
68
How many leads on a pacemaker
two
69
colonoscopy vagal nerve stimulation
hypotension
bradydysthythmias
ECG changes
--> ephedrine / glyco
70
ERCP, what med do you want to have available
glucagon
Sphincter of Oddi
71
complications of g tube placement
bleeding
injury to other structures
peritonitis
72
Venography is useful for assessing for
Budd Chiari
73
TIPS procedure is often used as a bridge for
liver transplant
74
Meds to avoid in IVF
droperidol
reglan
NSAIDS
sevo
des
morphine
75
meds safe in IVF
Midazolam
Ketamine
76
Essure procedure
need a negative pregnancy test
Pretreat with NSAIDS
preoperative anxiolytics
paracervical block with IV sedation
77
dental procedures
consider glyco for secretions
pain
sharing the airway
lido w epi 1:100,000
78
OMS
remifentanil
79
periodontics
Periodontists focus their work on bone loss and gums. Gingiva, connective tissue, periodontal ligament, alveolar bone & insertion, maintenance of dental dams
80
endodontics
An endodontist is a specialist who works on the inside of the tooth
81
ECT increases what
dopamine
serotonin
adrenergic transmission
Hypothalamic and pituitary hormones (antidepressant effects)
82
ECT increases
seizure threshold
83
ECT parasympathetic (tonic)
bradycardia
Hypotension
Bradydysthythmias
84
ECT synpathetic (clonic)
hypertension
tachycardia
85
meds safe for induction
methohexital
propofol
etomidate
succinylcholine
glyco / atropine
86
Meds that shorten seizure duration
diltizaem
diazepam
fentanyl
lidocaine
lorazepam
midazolam
propofol
sevoflurane
87
poctictal confusion
transient restlessness confusion agitation
88
extravasation of contrast media
apirate, elevate, ice, heat, assess for 2-4 hours,
89
MRI
LMA
90
harmful for MRI
ICD
pacemaker
heart valves
cochlear implant
deep brain neurostimulator
pacing wires
penile implants
eyeliner and pumps
91
zone 1
freely accessible areas
92
zone 2
reception area, changing room, MRI screenig room
93
zone 3
MR control room
94
Zone 4
Magnet room. walls of the magnet room contain five 0,5 mT lines of the fringe field of the magnet
95
MRI contrast
nonionic gadolinium
96
Magnetic fields under 2.5 T does not show adverse effects
97
PET scan
immmobile about 1 hour after the injection of FDG minimize the amount of the muscle uptake of the glucose-like substance
98
NPO for PET scan
minimize glucose levels
99
