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6901 > Laparoscopic/Robotic Surgery, Outpatient Anesthesia > Flashcards

Laparoscopic/Robotic Surgery, Outpatient Anesthesia Flashcards

(57 cards)

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1
Q

Laparoscopic surgeries vs robotic overall

A

Laparoscopic: General, gynecologic, urologic
Robotic: Can be applied to any subspecialty, use of this type is growing, GI/Cardiac/Thoracoscopic/urologic

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2
Q

Disadvantages to laparoscopy and robotics

A

Increased surgical expense

Longer operating time (until they’re proficient, takes 400 cases)

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3
Q

Advantages of laparoscopy and robotics

A 
Smaller incision
Decreased EBL
Decreased post-op pain
Decreased pulmonary morbidity
Shorter recovery/hospital stay
Less post-op ileus
Robotic prostatectomy-decreased incontinence and impotence
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4
Q

Contraindications to laparoscopy

A 
Diaphragmatic hernia
Acute/recent MI
Severe pulmonary disease
VP shunt
CHF or valve disease (Aortic stenosis, mitral valve regurg)
Hx CVA, cerebral aneurysm
Increased ICP
Glaucoma
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5
Q

Contraindications to robotic surgery

A

Poor pulmonary function test for robotic cardiac surgery - single lung ventilation may be poorly tolerated
History of stroke or cerebral aneurysm - prolonged Trendelenburg position

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6
Q

Closed technique for CO2 insufflation

A

Blind insertion of spring-loaded needle (veress needle) pierces the abdominal wall at thinnest point (sub-umbilicus)
Testing for placement:
-Aspiration/Irrigation (NS)/Aspiration (no return of NS=good placement)
-Hanging-drop test: Drop NS out of syringe onto hub of needle, drop should fall as abdominal wall is lifted
-Advancement test: If can advance 1cm deeper without resistance=good placement

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7
Q

Open technique for CO2 insufflation

A

Trocar placed under direct vision after midline vertical incision
-Avoids blind insertion like in closed technique so it’s safer but takes longer

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8
Q

CO2 insufflation

A

Creates a pneumoperitoneum
Standard to keep IAP below 15 mmHg
-Get significant physiologic changes at higher IAP

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9
Q

Why CO2 is the gas used for insufflation

A

Non combustible, more soluble in blood

  • Increased safety margin, decreased consequences of gas embolism
  • Rapidly returned from periphery and readily eliminated by the lungs
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10
Q

Cardiac arrhythmias during insufflation

A

Bradyarrhythmias, dysrhythmias, asystole
-Due to sudden stretching of the peritoneum - vagal tone
Treatment:
-Slow insufflation
-Give an anticholinergic
-If persisting/leads to HD compromise tell surgeon and release pneumoperitoneum

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11
Q

Hemodynamic effects of pneumoperitoneum

A 
Increased SVR (20%)
Increased MAP
-Due to increased sympathetic output from CO2 absorption and neuroendocrine response to pneumoperitoneum
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12
Q

What pressure should the IAP be kept to to minimize cardiovascular effects

A

12-15 mmHg

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13
Q

Why increased IAP leads to increased SVR and MAP

A

Activates the sympathetic system

  • catecholamine release
  • RAAS system
  • vasopressin release
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14
Q

IAP pressure effect on preload/intravascular volume

A

In hypovolemic patients: decreased preload because venous vessels are compressed
Increased intravascular volume when liver and spleen are compressed in steep Trendelenburg
-CO increase if IAP<15 (increased return)
-CO decrease if IAP>15 (decreased return, BP)

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15
Q

Physiologic effects of hypercapnia/respiratory acidosis

A
  • Pulmonary vasoconstriction
  • Decreased myocardial contractility
  • Increased arrhythmias
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16
Q

Insufflation effects on respiratory system

A

Decreased FRC
Decreased TLC -> atelectasis -> increased airway pressure
CO2 absorption plateaus in 10-15 minutes after initiation

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17
Q

Neuroendocrine response to pneumoperitoneum

A
  • Increased antidiuretic hormone

- Renal vasoconstriction/hypercarbia -> decreased renal blood flow

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18
Q

Local/regional anesthesia for laparoscopic surgeries

A

Shorter procedures with lower IAP (diagnostic procedure)

-Minimal head-down tilt

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19
Q

LMA anesthesia for laparoscopic surgeries

A 
Not routinely done in US, but proseal is used
Rule of 15s
-<15 minutes operating time
-15 degrees Trendelenburg
-15% above IBW
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20
Q

Anesthesia medication management for laparoscopic procedures

A

Use a short acting agent to speed recovery

  • Des or Sevo
  • Propofol TIVA
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21
Q

NMBD use for laparoscopic vs robotic surgery

A

Laparoscopic: Deep muscle paralysis isn’t necessary
Robotic: Paralysis is necessary for the entire case

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22
Q

N2O use for laparoscopic surgery

A

Controversial
Can diffuse into bowel lumen -> distension -> surgical access, increase PONV
No convincing evidence to avoid N2O unless high risk for PONV

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23
Q

Mechanical ventilation changes with laparoscopic procedures

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A

Decreased lung volume and pulmonary compliance, increased PIP
-May need to increase minute ventilation 20-30%, do this by increasing the RR not TV

24
Q

Extra monitoring for laparoscopic procedures

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A

Cerebral oximetry with prolonged steep head-up or head-down
Fluid minimization and goal directed administration
-With steep head-down pts are at risk for developing facial, pharyngeal, laryngeal edema and ischemic optic neuropathy
-High UOP may interfere with surgical procedure (robotic prostatectomy)

25
PONV for laparoscopic procedures
Pts with this type of surgery are high risk for PONV - Decadron 4/Zofran 4 - Hydration - Scop patch
26
ETT complication with pneumoperitoneum
Endobronchial intubation (from pressure on diaphragm) - Decreased SaO2 - Increased Pulmonary pressures
27
Most common respiratory complication during laparoscopy
``` Subcutaneous emphysema Predictors: -OR time >200 minutes -6+ surgical ports S/Sx: Sudden rise in ETCO2, increased pulmonary pressures ```
28
Pneumothorax and laparoscopy
``` Movement of gas through weak areas/defects in diaphragm S/Sx: -May be asymptomatic -Increased Peak pressures -Decreased SaO2 -Decreased BP ```
29
Gas embolism and laparoscopy
Low CVP increases risk of gas embolism -Rare but mortality rate 30% S/Sx: Decreased ETCO2, hypoxemia
30
Advantages to ambulatory surgery
- Cost effective - Patient satisfaction/convenience - Shorter waiting lists - Great flexibility for scheduling - Less preop testing, less postop meds - Lack of dependence on availability of hospital beds - Great efficiency/higher volume of patients - Low morbidity/mortality - Lower risk of nosocomial infections
31
Disadvantages for ambulatory surgery
- Reliable transportation and assistance with postop instructions - Person to remain with pt for 24 hours - Efficiency promotes discharge -> Less time to manage complications without backing up schedule - Lack of resources - Children have less time to adapt to surgical setting
32
Facility influences and considerations for ambulatory surgery
- OR schedule, production pressure - Anesthesia aids? - Equipment: emergency airway, blood, lab, medications - Staff: availability, education, training (ACLS?) - Size: unanticipated extended recovery time - Location of facility in relation to hospital - 23 hour observation: desired area for higher risk procedures
33
Procedure considerations for ambulatory surgery
Multiple planned procedures and duration >4 hours increases the risk of complications - Surgical complications=greatest cause of unanticipated hospital admissions - Blood loss, fluid shifts, N/V, Postop pain, invasive monitoring meds - Shouldn't require intense postop pain management
34
Liposuction ambulatory surgery
- <3000 mL go home - 3000-5000 consider overnight stay - >5000 overnight stay
35
Fluid management for liposuction ambulatory surgery
(IV fluid + infiltrate) / aspirate
36
Tumescent
Infiltrating NS or LR mixed with dilute amounts of epinephrine and lidocaine prior to suctioning - Provides hydro-dissection, improves hemostasis, and potentially provide perioperative analgesia - Limit lidocaine to 35mg/kg (55mg/kg is max)
37
General anesthesia for ambulatory surgery
-With or without peripheral nerve block PNB -Reduces opioid requirements and side effects Without PNB -Local wound infiltration -Exparel works for 72 hours (liposome injection of bupivacaine)
38
Patient influences for ambulatory surgery
- Social and physical support for 24 hours at home - Patient and family need to be able to understand instructions - Transportation to/from facility - Distance home from facility
39
Medical clearance for ambulatory surgery
Few absolute contraindications to ambulatory surgery | -Not determined by age, BMI, or ASA
40
Anesthesia clearance for ambulatory surgery
Schedule higher risk cases earlier in the day - Peds, diabetics, longer surgery, elderly - Morbid obesity (BMI>40) evaluated case by case
41
Patients at increased risk for postop complications from ambulatory surgery
- Potentially life threatening chronic illness (brittle diabetic, unstable angina, symptomatic asthma) - Morbid obesity with symptomatic cardiorespiratory problems - Multiple chronic centrally active drug therapy or active cocaine use - Ex-premature infant <60 weeks postconceptual age requiring general endotracheal anesthesia - No responsible adult at home to care for patient on evening after surgery
42
Cardiac risks for ambulatory surgery
<4-6 weeks after MI and angina symptoms have disappeared <4 weeks after angioplasty <4-6 weeks after bare-metal stent, <12 months after drug eluting stent if therapy needs to be d/ced for surgery Continue aspirin preop if possible
43
Temp that increases risk for ambulatory surgery
>37C
44
Key questions for preop assessment for ambulatory surgery
1: Is there any benefit to this patient being in the hospital overnight after surgery? 2: Is there anything that needs to be done to enable this patient to be a day case
45
Absolute contraindications for ambulatory surgery
No responsible caregiver Delayed recovery anticipated Severe uncorrectable CV disease
46
Fever considerations for ambulatory surgery (adults and peds)
Adults: URI delay surgery 6 weeks Peds: URI might delay surgery 2-4 weeks -If they are afebrile and have a normal appetite
47
H&P before surgery
Needs to be within 30 days
48
NPO guidelines for ambulatory surgery
``` Same as inpatient -Clear liquids: 2 hours -Breast milk: 4 hours -Light meal: 6 hours -Heavy foods: 8 hours Being liberalized, data showing no increased risk of aspiration and less time NPO -> less PONV ```
49
ASA status for ambulatory surgery
ASA III and IV depends on - Patients understanding/management of disease (extent/control of systemic disease) - Family support - Opinion of primary care physician
50
Premedications for ambulatory surgery
Versed -Given before induction decreases anxiety and postop nausea -Repeated dosing -> slower recovery -0.5mg/kg PO in peds allows separation from parents 15 mins after ingestion, doesn't prolong recovery COX-2 inhibitors aren't any more effective than traditional NSAIDS Tylenol-1 gram IV intraop resulted in therapeutic levels postop
51
Monitors for ambulatory surgery
Routine except temperature, only monitor if significant changes are intended, anticipated, or suspected (surgery >30 mins) -Continuous temp on all pediatric patients receiving general anesthesia
52
Propofol/TIVA with ambulatory surgery (Benefits, Delivery)
``` Benefits -No airway irritation -Rapid recovery, clear head -Decreased PONV Delivery -Target controlled infusion (TCI) in other countries monitors blood levels to adjust dose, not available in US ```
53
Inhaled anesthesia with ambulatory surgery
Most popular choice d/t ease of administration, controllability, and rapid emergence Sevoflurane -Associated with emergence delirium, esp in peds and teenagers (fentanyl, Propofol, midazolam reduce this) Desflurane -No differences in recovery room stay or PONV compared to sevo N2O -Improves quality and safety of induction, facilitates faster recovery, and reduces overall cost -No effect on N/V unless baseline incidence is high
54
LMA for ambulatory surgery
Associated with decreased sore throat, hoarseness, coughing, and laryngospasm compared to ETT
55
ProSeal LMA seal pressure
Up to 30 cm H20 - Increased seal pressure, reduced gastric inflation, provides gastric drainage - It's use for laparoscopic surgeries remains controversial
56
Discharge criteria for ambulatory surgery
``` A/O time and place VSS Pain controlled with PO meds N/V mild No unexpected bleeding Walk without dizziness Discharge instructions and prescriptions Accepts readiness for discharge Adult to accompany home *Not going to be "normal", return of psychomotor skills takes 24-48 hours *Voiding isn't essential *No major decisions or driving for 24 hours ```
57
Emergency medications required to be available at ambulatory surgery centers
Dantrolene (if triggering agents are used) IV lipids 20% if LA is used Surgeons should have admitting privilages at a nearby hospital

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