Plastics Flashcards
(89 cards)
1
Q
Most common plastic surgery complications are _____ & _____
A
DVT & PE
2
Q
Other common plastic surgery complications include:
A
Postop pain, nausea, & vomiting
3
Q
Plastic Surgery
Anesthetic Considerations
A
1° patient safety
DVT/PE prophylaxis
Liposuction guidelines on Lidocaine/Epi doses
Adequate hydration
4
Q
Most common plastic surgery procedure
A
Breast augmentation
Followed by liposuction, rhinoplasty, blepharoplasty, rhytidectomy (face lift)
5
Q
Preanesthesia Evaluation
A
CBC, BMP, coags, HFP, HIV, Hep B/C, HCG
Assess current medications - NSAIDs, vitamin E, contraceptives, weight loss, illegal drug use, prescriptions
Thyroid hormones, antidepressants, vitamins/minerals, herbals
Potential anticoagulant, antiplatelet, procoagulant effects, & effect on anesthetics
6
Q
What supplements have anticoagulant effects?
A
Alfalfa Dong quai Anise Saffron Bromelain Castanea sativa Ginseng Arnica Kelp Horseradish Red clover Asiatic ginseng
7
Q
What supplements have antiplatelet effects?
A
Fish oil Garlic Dong quai Celery Onion Clove Chili pepper Gingko biloba Black cohosh Licorice root Turmeric Vitamin E Asiatic ginseng
8
Q
Alternative preop medication to reduce anxiety
A
Melatonin 3-10mg ↓postop pain ↓opioid consumption Improve postop sleep quality ↓postop/emergence delirium ↓oxidative stress & anesthetic requirements
9
Q
Regional Anesthesia
Advantages
A
Fewer complications
Safer recovery
Improved postop analgesia
10
Q
BIS
A
Delay 15-30 seconds
11
Q
General Anesthesia
A
Risks include difficult or failed intubation, kinked/occluded ETT, dental damage, anesthesia gas machine errors, malignant hyperthermia
LMA frequently utilized
Room air general d/t airway fire risk
12
Q
Breast Blood Supply
A
Medial aspect = internal mammary artery
Lateral aspect = lateral thoracic artery
Venous drainage = superficial veins under dermis & deep veins parallel the arteries
Lymph drainage = retromammary lymph plexus in the pectoral fascia
13
Q
Breast Nerve Supply
A
Peripheral nervous system anterior & lateral cutaneous branches innervation 4th, 5th, & 6th intercostal nerves
Thoracic spinal nerve T4 innervates nipple-areola complex
14
Q
Breast Augmentation
Anesthetic Considerations
A
Healthy vs. breast cancer
General or regional
Cervicothoracic epidural or intercostal/fascial plane block
Position changes - secure head & arms to bed, eye protection, PIV extension tubing
Bra/binder place at end
15
Q
Cervicothoracic Epidural
A
C7-T4
Analgesia > general
16
Q
Fascial Plane Blocks
A
Adjunct block
No sympathetic blockade
Hemodynamic stability
17
Q
Breast Augmentation Incisions
A
- Infra-mammary
- Peri-areolar
- Trans-axillary
18
Q
Implants
A
Silicone or saline
Place in pocket under mammary gland or pectoralis muscle
19
Q
Breast Augmentation
Complications
A
Capsular contracture
Hematoma
Infection
Wound dehiscence
20
Q
Breast Surgery Lumpectomy
A
Wire-guided (radiology wire inserted under fluoroscopy)
Avoid muscle relaxants
< 1.5hrs
Outpatient procedure
21
Q
Sentinel Lymph Node Biopsy
A
Small, invasive breast cancer Axillary node dissection - NO relaxation Sentinel lymph node = 1st node to drain afferent lymphatics from lesion area Dye injected around breast Transient ↓SpO2 Pathology + nodes → axillary dissection
22
Q
Long Thoracic Nerve Damage
A
Motor
Winged scapula (scapula alata) d/t serratus anterior muscle paralysis
Complication from radical mastectomy or w/ axillary lymph node removal
23
Q
Thoracodorsal Nerve Damage
A
Motor
Results in latissimus dorsi muscle palsy
24
Q
Intercostobrachial Nerve Damage
A
Sensory
Numbness or pain in axilla lateral aspect & medial aspect upper arm
25
Intercostobrachial Neuralgia
Post-mastectomy pain syndrome
Numbness
Axilla, medial upper arm,& anterior chest wall pain
26
Lymphedema
Most common w/ axillary dissection & radiation
27
Mastectomy
Modified or partial - postop radiation/chemo
Total or simple - removes breast only
Radial - removes breast, pectoral muscle, & axillary lymph nodes
28
Mastectomy
| Anesthetic Considerations
```
Supine
Pox, PIV, & NIBP on opposite arm or LE
EBL 150-500mL
Admit overnight
1.5hrs
Reconstruction up to 7hrs
```
29
Avoid what medications during axillary dissection?
Muscle relaxants
30
Chemotherapy Complications
```
Cardiomyopathy
Anemia
Pulmonary fibrosis
Interstitial infiltrates
Pleural effusion
Myelosuppression
```
31
Radiation Complications
Respiratory or airway compromise possible
32
Breast Reconstruction
Immediate - temporary tissue expander or autologous myocutaneous flaps
Flaps = DIEP/SIEA/TUG/TRAM
33
Breast reconstruction relative contraindication:
Postop chest radiation
34
DIEP Flap
Deep inferior epigastric perforator flap
Abdominal skin, fat, & deep inferior epigastric vessels are removed & replanted to create new breasts
Internal mammary artery & vein are transected suprasternal & anastomosed to epigastric vessels
NO VASOPRESSORS
Avoid HTN or fluid overload
Indocyanine green to check tissue perfusion
ICU dispo, graft failure risk, venous congestion, fat necrosis, bleeding
35
Latissimus Dorsi Flap
Transfer back tissues (latissimus muscle, fat, blood vessels, & skin) to the mastectomy site
Thoracodorsal artery supplies the flap - left attached to its original supply
Turn patient lateral or prone
Overnight hospital admission
AVOID PHENYLEPHRINE
36
TRAM Flap
Transverse rectus abdominis myocutaneous - pedicle or free flap
Tummy tuck breast reconstruction
Skin, fat, & muscle tunneled from abdomen to chest
Avoid hypotension
Doppler to check perfusion
Flap based on superior epigastric vessels
AVOID PHENYLEPHRINE
37
Breast Reconstruction
| Anesthetic Considerations
```
Vascular access
MAP 85-100
Ephedrine > Phenylephrine
Avoid direct vasoconstriction
Heparin intraop
Foley catheter
Regional block postop pain management
NO nitrous oxide (interferes w/ healing)
```
38
Dextran
Flap procedures
Reduces clot formation in microvasculature
25-30mL/hr (low molecular weight)
Monitor allergic reactions ARDS
39
Breast Reduction
Reduction mammoplasty
Inferior pedicle w/ long curved horizontal incision across crease beneath breast
Inferior pedicle w/ vertical incision & short horizontal at crease (less scaring & shorter time)
+/- liposuction
40
Breast Reduction
| Anesthetic Considerations
```
General
Frequent position changes
3-5hrs +
Fluid warmer
Bair hugger
Foley catheter
Fluid/blood volume deficits
PONV
24hr stay
```
41
Breast Reduction
| Complications
```
Wound dehiscence
Infection
Seroma
Hematoma
Skin flap necrosis
Loss sensation
Hypertrophic scarring
```
42
Abdominal Surgeries
```
Liposuction
360° liposuction
Abdominoplasty
Tummy tuck
Abdominal muscle repair
Mommy makeover
```
43
Liposuction
2nd most common plastic surgery procedure
Removes fat from unwanted areas
Potential fat redistribution
Abdomen, hips, waist, torso, neck, extremities, pectoral region
Preop assess for cardiomyopathy, pulmonary disease, pulmonary embolus, thrombophilia
Relatively low risk procedure
Do not exceed 5% body weight (total volume < 5L)
Hypervolemia → hypovolemia, bleeding, electrolyte disturbances
44
What plastic surgery procedure has the highest morbidity & mortality?
Liposuction
45
Liposuction
| Dry Technique
Not recommended
Aspiration cannula inserted into space where fat will be removed
EBL 20-45% volume aspirated
46
Liposuction
| Wet Technique
200-300mL solution injected into each area to be treated
| EBL 1% volume aspirated
47
Liposuction
| Super-Wet Technique
Infiltrated solution = amount fat to be removed 1:1 ratio
| EBL 1% volume aspirated
48
Liposuction
| Tumescent Method
3-4mL solution per mL expected aspirate injected into fatty tissue
EBL 1% volume aspirated
49
Tumescent Solution
Removal SQ fat under anesthesia infiltrated w/ saline solution w/ Epi & Lidocaine
Used w/ general, spinal, or epidural
Requires monitoring, cardiac resuscitation, ventilatory support, recovery under anesthesia care
50
Klein's Solution
1% Lidocaine 50mL
1:1,000 Epi 1mL
8.4% NaH2CO2 12.5mL
1,000mL NS
51
Hunstad Solution
1,000mL LR (no burning sensation d/t reduced Na+ load)
1% Lidocaine 50mL
1:1,000 Epi 1mL
NO bicarbonate
52
Lidocaine Maximum Dose
```
FDA 35mg/kg (total body weight)
Dermatology or plastic surgery 55mg/kg
Anesthesiology 5mg/kg
Lidocaine w/ Epi 500mg
Epi 1:200,000 ↓SQ lidocaine absorption 50%
```
53
Total Adrenaline Maximum
50mcg/kg
54
Bicarbonate
↑pH
Helps to reduce pain
Facilitates faster entry into nerve cell where lidocaine acts therefore quicker onset
55
Liposuction
| Complications
```
LAST
Hypothermia
Fat embolism
DVT/PE
Acute anemia
Pulmonary edema
Fluid overload
Hemorrhage
Electrolyte imbalances
Nerve damage
Epi toxicity
Death
```
56
Liposuction
| IVF Management
< 4L = maintenance only
> 4L = MIVF + 0.25mL per mL removed after 4L
Goal to maintain normal intravascular volume w/ post-anesthetic Hct > 30% & albumin > 3g
57
Liposuction
| Anesthetic Considerations
```
General anesthesia
SCDs DVT/PE prophylaxis
Foley, Bair hugger, fluid warmer
Close incision sites w/ sterile dressings
Compression garment (binder)
Postop pain r/t amount fat removed
Tissue trauma d/t suctioning
```
58
360° Liposuction
Entire truncal midsection
Goal to complete curvier contour from every angle
Combination w/ dermolipectomy, rectus abdominis muscle plication, umbilicoplasty, or gluteal fat grafting
59
Abdominoplasty
Abdominal wall surgery
Umbilicus circumcised & blood supply preserved
Resect excess skin (pubis to costal margin)
Semi Fowler position on emergence & extubation
Combined w/ liposuction → lipoabdominoplasty
60
Abdominoplasty
| Anesthetic Considerations
2-5hr
Post gastric bypass ensure patients have stable weight 6mos prior to surgery
CBC, BMP, EKG, HFP
General anesthesia
Fluid warmer, Bair hugger, Foley, PIV, antibiotics
Prevent tension on suture lines (flexed table during surgical closure)
Postop PCA
61
Abdominoplasty
| Complications
```
Ileus
Infection
Dehiscence
Fat embolism
DVT
```
62
Mommy Makeover
Goal to restore shape & appearance after childbearing
Typically performed as single-stage procedure
Breast augmentation or lift, buttock augmentation, liposuction, tummy tuck, vaginal rejuvenation
Prevent DVT/PE, infections, postop pain
Abdominal contour surgeries consider spinal block up to T4
63
Autologous Fat Grafting
Transfer fat from one or more areas to other areas in order to improve body contour
Natural filler
Available & easy to obtain
Unpredictable % reabsorption
Most frequent areas = hips, buttocks, breast, face, & hands
Spinal > general anesthesia
64
Autologous Fat Grafting
| Phases
1. Harvesting adipose tissue
2. Processing lipoaspirate
3. Reinjection into receptor site
65
Cosmetic Facial Surgeries
```
Rhytidoplasty
Eyebrow lift
Rhinoplasty
Blepharoplasty
Buccal fat removal
Lip lifts
Chin implants
```
66
Rhytidoplasty
Face lift
Local anesthesia (subcutaneous & nerve blocks) + conscious sedation
Pre-medication (Melatonin, Lorazepam, Clonidine, Morphine, Fentanyl)
PONV prophylaxis
NO paralysis
Smooth emergence
67
Most common complication associated w/ rhytidoplasty:
Hematoma
68
Eyebrow Lift
Brow resuspension
Hair-line incision w/ flap
Possible laser use
69
Blepharoplasty
Lid lift
Periorbital fat manipulation
Possible laser use
70
Blepharoplasty Complications
Retrobulbar hematoma & blindness
| Occulocardiac reflex → bradycardia & hypotension
71
Facial Surgery
| Anesthetic Considerations
Brow, face, & lid lifts
```
Supine w/ HOB rotated away
LA w/ Epi
Antibiotics
Steroids
1-2hr procedures
Outpatient
Occulocardiac reflex → bradycardia & hypotension
LA w/ sedation - patient able to open & close eyes during procedure
```
72
Rhytidoplasty
Corneal protection
Nasal oxygen
Maintenance w/ Ketamine, Midazolam, Propofol, Dexmedetomidine, & opioids
Avoid general anesthesia (reserve for complex patients unable to tolerate/cooperate w/ conscious sedation)
Muscle relaxation not needed
Avoid coughing on extubation d/t bleeding at surgical site
73
Rhinoplasty
Nose surgical manipulation - aesthetic and/or functional improvement
Find out diagnosis/indication (billing)
Septorhinoplasty includes septum repair
Augmentation w/ silicon, gortex, synthetic material, cadaveric or autologous tissue (rib, cranium, iliac crest)
Open and/or closed surgery
Splint w/ nasal packing
Outpatient procedure
74
Rhinoplasty
| Anesthetic Considerations
MAC w/ infraorbital/nasocillary block
- Vasocontrictor-soaked packed placed prior to induction
- Safer to use general when ↑blood pooling
General anesthesia
- Regular ETT or oral RAE
- OG tube to remove blood in stomach
- HOB elevated
- Nasal packing (educate patient to breath through mouth)
- Smooth emergence
- PONV prophylaxis
Rotate HOB away from anesthesia gas machine (consider positioning & vascular access)
75
COMPLICATIONS & DEATH
Bronchospasm
Deep sedation
Illicit drug use
Thromboembolism
76
How to prevent poor outcomes?
Appropriate pre-anesthetic evaluation
Informed consent
Appropriate monitoring
Appropriate anesthesia & postanesthetic care
77
DVT/PE Prophylaxis
Compression stockings
Intermittent pneumatic compression tools SCDs
Venous foot pumps
Low molecular weight heparin
78
What contributes to anesthesia complications?
Longer anesthesia times
↑complication risk
Bleedings, atelectasis, DVT/PE, immune response
79
PONV Complications
Most common & unfavorable complication after surgery
| ↑bleeding, delayed discharge, $$$
80
PONV Treatment
```
Dexamethasone & Ondansetron useful & low cost
10mg Propofol (1-2cc)
```
81
Burns
Wound coverage w/ autograft or synthetic/biological dressing
Early & frequent eschar removal
Debridement every 2-3 days
82
Tangential Excision
Eschar slices are shaved sequentially until healthy wound bed developed
Epi & tourniquet per surgeon to prevent & ↓blood loss
83
Facial Excision
Removes eschar & underlying tissues down to the muscle fascia
More rapid & less blood loss than tangential excision
Cosmetic deformities & functional loss may occur
84
Burn
| Anesthetic Considerations
Surgery scheduled once patient fluid resuscitated
Performed every 2-3 days
Endpoint = OR time > 3hrs, core temp < 35°C, blood loss > 10 units PRBCs
Type & screen w/ PRBCs present in room & on hold
Room temp 82-100°F
Caution w/ Epi
Antibiotics & antisepsis
ICU
Pain management
85
Rule of 9s
Estimate burn severity
18-40% mortality correlates w/ burn area
```
Head 9%
Anterior chest 18%
Posterior chest 18%
Arms 9% each
Legs 18% each
Perineal 1%
```
86
Burns Preop
Assess respiratory involvement (upper or lower airway)
Inhalational smoke/burns → airway edema
Cardiac hypermetabolism
nAChR up-regulation ↓sensitivity to NDMR ↑K+ w/ Succinylcholine
Hct/Hgb & coags
PIV vs. central line
87
Burns Intraop
OPIOIDS/NARCOTICS
GETA (no LMA d/t airway edema)
Potentially suture ETT when facial burns present
Induction w/ Ketamine or Etomidate
> 30% total body surface area burns ↑NDMR dose
88
Burns Maintenance
Respiratory compromise + hypermetabolic state → ↑minute ventilation, inspiratory pressures, PEEP
Warm room & IV fluids
Prepare for blood loss
- Large bore PIVs x2, cordis, and/or CVC
- Blood loss 200mL per 1% body surface area excised & grafted
89
Burns Emergence
Narcotic use & fluid resuscitation - remain intubated
Transport w/ monitor, emergency meds/airway, PEEP
Monitor labs
