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Principles of Anesthesia > General and Gynecologic Surgery (Exam III) > Flashcards

General and Gynecologic Surgery (Exam III) Flashcards

1
Q

When was laparoscopy first used?
What for?

A

1970’s for gynecologic conditions

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2
Q

What is the purpose of gastric insufflation?

A

Allows for room to work inside peritoneum

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3
Q

What occurs with the initial insufflation of the abdomen?

A

Release of catecholamines & vasopressin.

Arterial vasculature is compressed.

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4
Q

What is the goal pressure in mmHg for gastric insufflation?

A

≤ 20 mmHg

12 - 15 mmHg is most common.

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5
Q

What causes increased CO₂ during laparoscopic surgeries?

A
  1. Positioning (frequently Trendelenburg)
  2. CO₂ insufflation (absorbed by peritoneum into the blood stream).
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6
Q

What are the pulmonary effects of insufflation?

A
  • ↑ PaCO₂
  • ↓ compliance
  • ↑ PIP
  • ↓ FRC
  • Atelectasis
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7
Q

In what laparoscopic position is atelectasis development most common?

A

Trendelenburg

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8
Q

How much change in pulmonary compliance occurs with gastric insufflation?

A

30 - 50% decrease in compliance

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9
Q

Is increased PaCO₂ in laparoscopic cases primary from diaphragm displacement or CO₂ absorption?

A

Primarily from diaphragm displacement.

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10
Q

When does the increase in PaCO₂ from gastric insufflation plateau?

A

10 - 15 min

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11
Q

How does the CRNA typically treat hypercarbia secondary to gastric insufflation?

A
  • ↑ VT or RR
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12
Q

When would the CRNA be hesitant to treat a hypercarbic patient?

A

Towards the end of the case.

↑ CO₂ necessary to stimulate respiratory drive and facilitate extubation.

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13
Q

What typically causes pulmonary complications in laparoscopic cases?

A

Improper trocar placement

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14
Q

What are the pulmonary complications associated with improper trocar placement?

A
  • SubQ emphysema, pneumothorax, etc
  • Gas embolism
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15
Q

What pulmonary complication is the result of CO₂ insufflation pushing the carina upwards?

A

Migration of ETT from carina to the bronchus (endobronchial intubation)

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16
Q

What’s the hemodynamic result of a gas embolism into the vena cava?

A

Massive CO drop

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17
Q

What are the s/s of gas embolism?

A
  • ↓ EtCO₂ (best early sign)
  • ↑ HR
  • Dysrhythmias
  • ↓ BP w/ ↑ CVP
  • Millwheel murmur
  • Hypoxemia
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18
Q

What is the treatment for CO₂ gas embolism?

A
  • Cessation of insufflation
  • Trendelenburg
  • Fluid bolus
  • 100% O₂
  • Aspiration of air
  • Vasopressor support
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19
Q

How is endobronchial intubation detected?

A
  • Loss of bilateral breath sounds
  • ↓ pulse oximetry
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20
Q

At what intraperitoneal pressure do the hemodynamic effects of insufflation set in?

A

> 10 mmHg IAP

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21
Q

What hemodynamic changes are seen with insufflation?

A
  • ↓ CO
  • Reflexive ↑ BP
  • Reflexive ↑ SVR
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22
Q

What drugs would be best for the reflexive hypertension from CO₂ insufflation?

A
  • VAA
  • Nitroglycerin
  • Nicardipine
  • Remifentanil
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23
Q

How much do cardiac arrhythmias increase with increased PaCO₂?

A

Trick question. Arrhythmias arise from hypoxia not from hypercarbia.

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24
Q

What often causes cardiac arrythmias in laparoscopic cases?

A

Increases in vagal tone

  • Peritoneal stretch
  • Pulling on cervix
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25
Q

How would the bradycardia from vagal stimulation be treated?

A
  • Limit insufflation pressure
  • Glycopyrrolate
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26
Q

In what position would one expect possible injury to the peroneal nerve or even compartment syndrome?

A

Lithotomy

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27
Q

What is the most common surgical complication of laparoscopy?

A
  • Intestinal injury (perforation, CBD injury)
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28
Q

What are the possible surgical complications of laparoscopy?

A
  • Intestinal injuries
  • Vascular injuries
  • Burns
  • Infection
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29
Q

When is laparoscopy contraindicated?

A

Patient with ↑ ICP (tumor, trauma, etc.)

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30
Q

Is LMA a good option for Laparoscopic procedures?

A

Not really, insufflation can displace the LMA.

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31
Q

What are the reasons for OGT/NGT insertion in laparoscopies?

A

Aspiration of stomach air so surgeon has better visualization.

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32
Q

What important part of the SCIP protocol is anesthesia in charge of now?

A

Antibiotics

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33
Q

What are the two most common firstline antibiotics indicated by the SCIP protocol?

A
  • Cefazolin
  • Cefoxitin
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34
Q

What is the most common antibiotic indicated by the SCIP protocol for those with severe penicillin/cephalosporin allergy?

A

Vancomycin

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35
Q

What are the other factors important to the SCIP protocol besides antibiotics?

A
  • β-blockers
  • Temperature
  • Time Out
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36
Q

What severe complications of GERD are avoided by a Niessen fundiplocation?

A
  • Stricture
  • Aspiration PNA
  • Esophageal Ulcerations
  • Barret’s Esophagus
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37
Q

How do prokinetic drugs work?
Which ones are commonly given?

A
  • Strengthen LES & increase gastric emptying
  • Metoclopramide & cisapride
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38
Q

How do PPI’s work?

A

Blockade of ATPase in parietal cells

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39
Q

What intubation technique is indicated for Niessen patients?

A

RSI

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40
Q

What position is indicated for Niessen Fundiplocations?

A

Supine, Low lithotomy, Head up

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41
Q

What piece of equipment (unique to Niessen Fundiplocations) should the CRNA be prepared to use?

A

Esophageal Dilator

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42
Q

What size is the esophageal dilator used for Niessen’s?

A

60 fr

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43
Q

In what surgery is the Triangle of Calot relevant?

A

Cholecystectomy

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44
Q

What structures are isolated and stapled during a cholecystectomy?

A
  • Cystic artery and hepatic duct
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45
Q

What are the indications for Cholecystectomy?

A

Symptomatic cholelithiasis
Symptomatic cholecystitis

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46
Q

Who is most at risk for gallbladder disease?

A

5 F’s

  • Female
  • Forty
  • Fair (caucasian)
  • Flatulent
  • Fat
47
Q

What drugs should be considered for an emergent gallbladder?

A
  • Prokinetics
  • Bicitra
48
Q

What position is a gallbladder placed in for surgery?

A
  • Supine
  • Head up
  • Left tilt
49
Q

How is a sphincter of Oddi spasm treated?

A

Glucagon

50
Q

When would an ERCP be indicated?

A

Choledocholithiasis

51
Q

What are indications for Spleenectomy?

A
  • ITP (Immune thrombocytopenic purpura)
  • Lymphoma
  • Hemolytic anemia
  • Trauma
52
Q

What vaccines should have been received one week prior to spleenectomy?

A
  • Pneumococcal
  • Meningococcal
  • H. Influenza
53
Q

With what pathology would one expect left lower lobe atelectasis?

A

Spleen problems (inflammation → swollen → pushes on LLL)

54
Q

In what surgery would the CRNA anticipate having a type and screen or a type and cross ready?

A

Spleenectomy

55
Q

Differentiate a type and screen and a type and cross. (very superficially)

A
  • Type & Screen = blood type identified
  • Type and Cross = blood type identified and bags are ready down in blood bank.
56
Q

What position would one place a spleenectomy patient in?

A
  • 45° right lateral decubitus
57
Q

What are some indications for bowel resection?

A
  • Ulcerative colitis
  • Crohn’s
  • Diverticular disease
  • Cancer
  • Ischemic bowel
58
Q

What is necessary pre-operatively for bowel resection patients?

A
  • Bowel prep
  • μ-opioid antagonists
  • ERAS protocol
59
Q

What would be the purpose of a μ-opioid antagonist prior to bowel surgery?

A

Counteracts constipatory effects of narcotic and results in a faster resolving ileus.

60
Q

What is the ERAS protocol?

A

Enhanced Recovery After Surgery.

Has many components but some examples are:
- Pre-op warming
- Multimodal anesthesia
- Proper hydration preoperatively

61
Q

With which surgery might the CRNA more readily consider albumin vs crystalloids?

A

Bowel resection

62
Q

What positions are used commonly for bowel resections?

A

Supine & low lithotomy

(can range all the way to very high lithotomy)

63
Q

What is the indication for appendectomy?

A

Suspected appendicitis

64
Q

Why might appendectomy patients be dehydrated?

What are the most commonly used labs to note this dehydration?

A
  • Dehydration d/t fever & N/V
  • Hemoconcentration (H/H), ↑ BUN
65
Q

What positioning is utilized for appendectomy patients?

A

Supine, left arm tucked, trendelenburg (head down)

66
Q

Which two gastric surgeries result in rapid initial weight loss?

A

Sleeve Gastrectomy & Gastric Bypass

67
Q

In what gastric surgery would one expect protein and nutrient absorption to be the most affected?

A

Gastric Bypass

68
Q

What is the primary adverse event associated with lap banding surgery?

A

Band erosion

69
Q

Which bariatric surgery is characterized by better nutrition, easier removal, and less significant weight loss?

A

Lap Banding

70
Q

What are some possible indications for Bariatric surgery?

A

Morbid Obesity associated with:

  • HTN
  • DM
  • OSA
  • Asthma
71
Q

What parameters (generally) result in approval from insurance companies for bariatric surgery?

A
  • BMI > 35 w/ comorbidities
  • BMI > 40
72
Q

What possible homeopathic remedies for appetite suppression should be considered for patients receiving bariatric surgery?

A

G - Supplements (gingko, green tea, etc.)

73
Q

Prophylaxis for ____ is important for bariatric surgeries.

A

VTE

74
Q

Bariatric surgery patients commonly have undiagnosed ____.

A

OSA

75
Q

What position is typically used for bariatric surgeries?

A
  • Head up at 30°
76
Q

What positioning do obese patients generally not tolerate?

A

Supine (or also head down)

77
Q

What s/s is more common post lap banding surgery?

A

Dysphagia

78
Q

What are some concerns for patients post-operative bariatric surgery?

A
  • Diarrhea
  • Dysphagia
  • Protein malabsorption
  • Vitamin malabsorption
79
Q

What are some indications for conversion of laparoscopy to laparotomy?

A
  • Obesity
  • Adhesions
  • Bleeding
  • Unclear anatomy
  • Staple misfire
  • Inability to ventilate
80
Q

What are some indications for exploratory laparotomy?

A
  • Trauma
  • Abdominal catastrophes (ex. ischemic bowel)
  • Cancer staging
81
Q

With what surgeries would the CRNA consider an epidural placement?

A

Laparotomies

82
Q

____ are necessary for the inevitable ileus in post-operative laparotomies.

A

NGT’s

83
Q

What surgeries are often at risk for PONV?

A

Gynecologic surgeries

84
Q

What risk factors for PONV exist with gynecologic surgeries?

A
  • Female
  • Opioids
  • VAA’s
85
Q

What would tend to cause bradycardia during a dilation and curettage (D&C) procedure?

A

Cervix manipulation via the tenaculum

86
Q

What complications should the CRNA consider post D&C ?

A
  • Sepsis
  • Hemorrhage
87
Q

What positioning is utilized for both a D&C and a D&E ?

A
  • Lithotomy
88
Q

Which surgeries are SCIP protocol not indicated on?

A

D&C and D&E

89
Q

Where is oxytocin secreted from?

A

Neurohypophysis

90
Q

What does oxytocin do?

A
  • Stimulate uterine contraction
  • ↑ H₂O reabsorption from glomerular filtrate
91
Q

What is the name for synthetic oxytocin?

A

Pitocin

92
Q

What procedure allows for examination of the endometrial cavity?

A

Hysteroscopy

93
Q

What two fluids are used for hysteroscopy?

A
  • NS
  • Sorbitol
94
Q

What equipment should be used if NS is used in a hysteroscopy?

A

Bipolar Cautery

Monopolar cautery + NS = burns

95
Q

When should sorbitol be avoided?

A

With diabetic patients

96
Q

When should glycine irrigation be avoided?
Why is this?

A

Avoided in liver patients due to the buildup of ammonia

97
Q

What are the two typical anesthetic options for hysteroscopy?

A
  • Paracervical block
  • General w/ LMA
98
Q

What would most likely cause bradycardia during a hysteroscopy?

A

Vagal response of cervix manipulation w/ tenaculum

99
Q

What are urethral slings used to treat?

A

Incontinence

100
Q

Who is at risk of incontinence requiring a urethral sling?

A
  • Multiparous women (older)
  • Nulliparous young athletes
101
Q

What type of anesthesia is typically performed for urethral sling patients?

A

General w/ LMA

102
Q

What is the sling material made of in urethral sling procedures?

A

Prolene mesh

103
Q

Loss of support to the ____ ____ and the ____ ______ is responsible for incontinence in patients requiring urethral sling.

A

bladder neck ; pelvic floor

104
Q

What equipment is necessary for Condyloma removals?

A
  • Laser masks
  • Smoke evacuation system
105
Q

What causes pelvic organ (bladder, vagina, etc) prolapse?

A

Weakened pelvic floor

106
Q

What are the three types of prolapse discussed in lecture?

A
  • Cystocele (bladder)
  • Rectocele (rectum)
  • Enterocele (intestine)
107
Q

What medical device do patients typically go home with post prolapse repair?

A

Foley catheter (ensures urethra won’t be obstructed)

108
Q

What are the three types of hysterectomy?

A
109
Q

What two types of cut are used in hysterectomies if an abdominal approach is indicated?

A
  • Pfannenstiel (bikini cut)
  • Midline
110
Q

What is the most common surgical approach for hysterectomies?

A

LAVH

Laparoscopic assisted vaginal hysterectomy

111
Q

What benefits does robotic surgery provide?

A

Increased safety profile

Ex. Impotence rates decreased post implementation of robotic surgery for prostatectomies

112
Q

What are the pros and cons of robotic surgery?

A
  • Improved dexterity
  • Increased cost & OR time
113
Q

What positioning is typically used with robotic surgery?

A

Extreme Trendelenburg

114
Q

Robotic surgeries necessitate less fluid administration. Why?

A

Positioning (severe trendelenburg) results in extreme facial and airway edema.

Principles of Anesthesia (24 decks)

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