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734 > GI Anesthesia > Flashcards

GI Anesthesia Flashcards

(91 cards)

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1
Q

Cause of right mainstem during laparoscopy

A

Displacement of the diaphragm into the thorax caused by abdominal insufflation (trendelenburg)

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2
Q

Trendelengburg

A

Head down

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3
Q

Reverse trendelenburg

A

Head up

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4
Q

Impacts of severe hypercarbia

A

Myocardial depression
Dysrhythmias
Systemic vasodilation

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5
Q

Impact on the cardiopulmonary system from hypercarbia

A

Hypercarbia induced pulmonary vasoconstriction acutely elevated right ventricular afterload

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6
Q

Why do obese patients tolerate insufflation better?

A

Intrinsically elevated IAP

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7
Q

Problems with COPD and pneumoperitoneum

A

Hypercarbia may be refractory to hyperventilation

Increased alveolar physiologic space in these patients leads to a wide PaCO2-ETCO2 difference=monitoring may underestimate the actual CO2

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8
Q

Renal function and pneumoperitoneum

A

It’s reduced! Surprise!

However… reduction in renal perfusion induces vasopressin release which results in reduced free water excretion and is associated with an increase in abdominal cavity pressure

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9
Q

Explain the debate about high O2 concentrations

A

High concentration PROs: reduced PONC, improved wound healing, and optimal VQ matching

Cons: alveolar nitrogen washout and subsequent absorption ateletasis, reactive o2 species cause cellular injury, and pulmonary oxygen toxicity

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10
Q

Fluid management

A

Hard to pinpoint

But in healthy patients increased intraoperative fluid loading is associated with improved postoperative pulmonary function, exercise capacity, and overall well being

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11
Q

Main complication in laparoscopy

A

Needle/trocar insertion

Be prepared for severe hemorrhage but routine preop t/s is not necessary

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12
Q

Define subcutaneous emphysema

A

Introduction of CO2 gas into subcutaneous, preperitonneal, or retroperitoneal tissue leading to trapped gas pockets

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13
Q

Risk factors and treatment of subQ emphysema

A

Longer than 3.5 hours
IAP>15mmhg
# surgical ports
ETCO2> 50mmhg

-hyperventilation, deflation

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14
Q

Capnothorax, define and treat

A

CO2 accumulation in the pleural space

Desufflation, hyperventilation

Severe: needle decompression

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15
Q

Laparoscopy disadvantages

A

Pneumoperitoneum- CO2 related, stress response

Visceral injury/hemorrhage

Increased surgery time

Position injuries

Blood loss ambiguous

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16
Q

Why CO2 in pneumoperitoneum?

A

Non-toxic
Non-flammable
Minimal air embolus

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17
Q

Neurohormonal effects of CO2

A

Increased levels of catecholamines
-dopamine, epinephrine, norepinephrine

Increased renin
Increased vasopressin

=Increased SVR

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18
Q

Cause of post op shoulder pain in pneumoperitoneum

A

Carbonic acid is a peritoneal irritant and causes referred pain

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19
Q

Metabolic derangement created by CO2

A

Respiratory Acidosis

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20
Q

How does pneumoperitoneum affect venous return?

A

Increases

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21
Q

How does pneumoperitoneum affect stroke volume?

A

Decreases

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22
Q

How does reverse trendelenburg affect preload?

A

Increases

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23
Q

Describe pneumoperitoneum impact on the respiratory system?

A

Diaphragm displaced

Carina shifted cephalad

Lung volumes decreased

Hyperventilation to normalize CO2

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24
Q

Splanchnic and pneumoperitoneum

A

Decreased blood flow via external compression and systemic vasoconstriction

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25
Mesenteric impact of pneumoperitoneum
Ischemia from insufflation pressures of 10-14mmhg
26
Long periods of insufflation will do what to the renal system?
Oliguria -decreased pressure
27
Anesthesia preop management for laparoscopy
Aspiration prophylaxis Fluid loading
28
Intraop anesthetic management for laparoscopy
GETA PEEP Recruitment maneuvers Muscle relaxation Avoid N2O…
29
N2O and the bowel
30x more soluble in the blood than N2 Diffuses rapidly into gas cavities May lead to: distention ischemia difficult surgical exposure PONV
30
Why don’t we use N20 for insufflation?
Combustible
31
What does bowel perforation liberate?
Methane/hydrogen
32
What are we confirming with position changes in laparoscopy?
ETT -mainstem
33
PONV in Laparoscopy
As high as 72% Leads to: wound dehiscence, aspiration, hospital admission TIVA decreases incidence to 10%
34
How to treat referred shoulder pain?
NSAIDs (ketorolac)
35
What interesting thing are we using for pain in laparoscopy?
Lidocaine Reduces post op pain, PONV, early return of GI function
36
Laparoscopy complications
Visceral/vessels punctures Urinary injury Subcutaneous emphysema Gas embolism- microemboli VERY common
37
Gas embolism signs
Decreasing End tidal Cardiovascular changes- tachycardia, arrhythmias, hypotension, CV collapse
38
What decreases in gas embolism?
PCO2 Oxygen saturation Blood pressure
39
What increases in gas embolism?
End tidal nitrogen PA pressures Dysrhythmias Cyanosis Hypoxia “Mill-wheel”murmur
40
MANAGING Gas embolus
Stop insufflation Eliminate N20 Flood field Left lateral decubitus Aspirate with CVC Support
41
Durant maneuver
Left lateral decubitus
42
What do we ALWAYS do with concerning changes in pneumoperitoneum
Deflate the Michelin man Until problem is identified
43
Barrett’s esophagus
Pre-malignant changes from chronic reflux
44
Achalasia
Dilation of distal esophagus w/frequent regurgitation due to impaired lower esophageal sphincter relaxation
45
Hiatal hernia
Herniation of abdominal contents through esophageal hiatus into the mediastinum -associated with GERD and esophagitis
46
Type 1 hiatal hernia
“Sliding type”- upper stomach only moves through the enlarged esophageal hiatus
47
Type II hiatus
Paraesophageal type- all or part of the stomach moves into the thorax
48
Type III hiatus
MIXED type of I and II
49
Type IV hiatus
Most severe, other organs such as bowel may be contained in the hernial sac
50
UES
Upper esophageal sphincter -pharyngoesophageal junction Tonic contraction 15-60 cmh20 Seals upper esophagus from hypopharynx
51
LES
Lower esophageal sphincter Border of esophagus and stomach Resting tone 15-20 cm h20
52
Barrier pressure
LES minus gastric pressure
53
Managing esophageal disorders (medical)
Antacids Mucosal protection agents H2 blockers PPIs Prokintetics
54
Anesthetic management of esophageal disease
Aspiration prophylaxis RSI w/cricoid or awake fiber optic
55
Nissan fundoplication
Intervention for GERD or hiatal hernia -usually laparoscopic GETA and muscle relaxation PONV prophylaxis!!!
56
When are we paying attention in Nissan fundoplicaiton?
During placement of esophageal bougies (dilators)
57
Cholecystitis
Obstruction or infection 90-95% due to gallstones Labs: increased-bilirubin, alkaline phosphatase, amylase Leukocytes is and fever
58
Murphys sign
Inspiratory efforts is painful Indicative of Cholecystitis
59
Anesthetic management of cholecystectomy
Rehydrate GETA OGT for decompression Glucagon admin during cholangiogram Postop:shoulder pain-abd pain may last for years
60
Glucagon dosing
<2mg otherwise nausea
61
Know anatomy of the small intestine!
Starts with Pyloric sphincter Jejunum Ileum Ends with ileocecal valve
62
General anesthetic considerations in large and small bowel surgeries
Aspiration Hypovolemia PH/electrolyte imbalance Fluid shifts Avoid N20 Pain management
63
Crohn’s disease
Commonly impacts distal ileum and proximal large colon -advanced disease=malabsorption and protein loss-anemia is common Fistulas common
64
Medical management of crohns
Sulfasalazine Glucocorticoid Immunotherapy Immunomodulators
65
Anesthetic considerations for crohns bowel resections
Stress dose steroids for patients on chronic glucocorticoids Fluid electrolytes anemia Pain-consider epidural
66
Ulcerative colitis
Inflammatory disease causes ulceration of colonic mucosa (extends proximally from rectum -treat similarly to crohns
67
Difference between crohns and ulcerative colitis
UC surgical intervention is often curative with large bowel resection and ileostomy
68
Pathophys of excess serotonin
Vasoconstriction Increased intestinal tone Water and electrolyte imbalance-diarrhea Hypoproteinemia Hyperglycemia Plaque formation
69
Carcinoid syndrome
Slow growing SI tumors that arise form enterochromaffin cells in GI tract Release vasoactive substances-serotonin/kallikrein/histamine If limited to the GI tract the liver can process these substances
70
Carcinoid syndrome symptoms
Cutaneous flushing Bronchoconstriction Hypotension Diarrhea Heart disease
71
What do we clarify with endocrinologist in carcinoid syndrome
Octreotide administration
72
Anesthetic management of carcinoid syndrome
Avoid provoking release of vasoactive substances! -avoid: ketamine, ephedrine, epi, norepi -morphine, succinylcholine Treating crisis: octreotide: 150-200mcg Q6-8hrs Phenylepherine and volume
73
Treating bronchospasm in carcinoid syndrome
Octreotide
74
75
How much pressure causes injury?
20-30 mmhg
76
Explain shoulder pain in laparoscopy
CO2 accumulation (ie carbonic acid buildup) irritates the phrenic nerve
77
Henrys law
Henry's law is a gas law that states that the amount of dissolved gas in a liquid is directly proportional at equilibrium to its partial pressure above the liquid.
78
What are we looking for during inflation?
Baroreceptor response Bradycardia and cardiac arrest -have glyco on hand
79
Effects of hypercapnia on the lungs
Pulmonary vasoconstriction leading to increased right ventricular afterload
80
81
How does insufflation impact map and co?
Map increases Co decreases
82
Stats on trocar insertion injury
They occur in 1% of surgeries And Cause 50% of injuries…
83
Biggest determinant of esophageal reflux
Barrier pressure
84
In gastric cases what do you not pull out at the end of the case?
Nasogastric tube
85
What does glucagon do?
Spasmolysis at sphincter of Oddi
86
Carcinoid triad of symptoms
Diarrhea Flushing Cardiac-(heart disease)
87
Diagnosing carcinoid syndrome
Elevated levels of serotonin metabolites in the urine
88
Histamine releasing drugs we avoid in carcinoid syndrome
Morphine Atracurium
89
Big consideration in pancreaticoduocenctomy (Whipple)
Put in a-line/cvc You’re gonna give blood
90
91
Carcinoid crisis dosing
Treat crisis with octreotide: 150mcg-200mcg Q 6-8hrs during AND for 24-48 hours prior to surgery.

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