Types of General Surgery Part III Flashcards
(111 cards)
1
Q
Common laparoscopic GI procedures include:
A
cholecystectomy- removal of disease gall bladder
herniorrhaphy- defect in muscles of abdominal wall
appendectomy- most common acute surgical procedure of the abdomen- obstruction/inflammation due to lymphoid tissue or fecal matter
2
Q
Cholecystectomies can be performed due to
A
cholecystitis, cholelithiasis, cancer
3
Q
Types of hernias include
A
inguinal, umbilical, incisional, abdominal, femoral, & diaphragmatic
4
Q
Cholecystectomies can be performed
A
laparoscopic versus open
rate of conversion 5-10%
concern is a Sphincter of Oddi spasm
5
Q
Risk factors for conversion to open for a cholecystectomy includes
A
acute cholecystitis with thickened gallbladder wall previous upper abdominal surgery male gender advanced age obesity bleeding bile duct injury
6
Q
Potential cholecystectomy complications include
A
bleeding from cystic artery & cystic duct liver laceration
pneumothorax
7
Q
Considerations for cholecystectomy include
A
preoperative antibiotics are controversial
DVT prophylaxis
8
Q
Positioning for cholecystectomy include
A
surgeon on patient’s left (supine) or between patient’s legs (lithotomy)
Reverse Trendelenburg, left tilt (right side up)
9
Q
Herniorrhaphy is performed
A
outpatient, elective surgery
open versus laparoscopic
10
Q
If a hernia is not reduced,
A
there is potential for incarceration which makes it an urgent surgery
11
Q
Strangulated hernia is
A
an emergency surgery, GA–> can lead to necrotic bowel requiring bowel resection
12
Q
Anesthetic considerations for hernia surgery include
A
avoid strain (smooth emergence)
anesthetic choice: GA, local, or regional (T8)
EBL~50 mL
postop pain is 4-6
LA infiltration of ilioinguinal and iliohypogastric nerves
bradycardia due to peritoneal retraction
13
Q
GI lab diagnostics include
A
esophagogastroduodenoscopy (EGD), endoscopic retrograde cholangiopancreatography (ERCP), colonoscopy
14
Q
Appendectomies are performed for
A
appendicitis (presenting as pain, anorexia)
mortality 1% (2% if perforated)
incidence of 6% of population
15
Q
The anesthetic technique utilized for appendectomies includes
A
GA (RSI?), OGT, avoid N20, give antibiotics
16
Q
Considerations for appendectomy include
A
fluid & electrolyte deficits, aspiration precautions, avoid metoclopramide with obstructions, skeletal muscle relaxation
17
Q
Colonoscopies are done to
A
view the lining of the rectum and colon- cancer screening, treatment of polyps
18
Q
Potential complications of colonoscopy & EGD include
A
perforation, bleeding, desaturation, and laryngospasm (due to spontaneous breathing as it is a room air general)
19
Q
Considerations for colonoscopy include
A
colon prep, clear liquid diet
- left lateral decubitus
- usually heavy sedation or GA
20
Q
Considerations/positioning for EGD includes
A
supine or lateral decubitus
conscious sedation/topical, GA
21
Q
When performing an EGD, there is
A
shared airway/limited access
mouth-piece inserted by endoscopist to prevent biting
may consider GETA (obese, risk factors)
if there is any food that is found when endoscope is inserted then it needs to be aborted
22
Q
Indications for esophageal surgery include
A
GERD, CA, hiatal hernia, motility disorders
23
Q
Patient symptoms indicating need for esophageal surgery include
A
dysphagia, heartburn, hoarse voice, & chest pain
24
Q
ERCP is performed to
A
diagnose and treat pancreatic and biliary disorders
25
Complications of ERCP include
perforation, bleeding, laryngospasm, and desaturation
26
Surgical considerations for ERCP include
GETA or sedation, length is 30 minutes to several hours, use of contrast dye
left lateral decubitus/prone (may change during procedure)
27
A Nissen fundoplication is
when the fundus is wrapped around lower esophagus and sutured to reinforce lower esophageal sphincter
can be laparoscopic or transthoracic (open) approach
surgical time: 3-4 hours
28
Considerations for a Nissen fundoplication include
54-60 French esophageal dilator (Bougie), NG tube 12-24 hours postop, pneumatic compression stockings, smooth extubation
29
Medications that should be given for Nissen fundoplication include
H2 blockers, metoclopramide (2-4 hours preop), antibiotic, and antiemetics
30
Nissen fundoplication are performed via
GETA
induction include: position, RSI w/ cricoid pressure
lithotomy and reverse Trendelenburg positioning
31
Indications for esophagectomy include
ETOH, tobacco, chemo/radiation
32
Anesthetic considerations for esophagectomy are
surgical approach, invasive monitors, double-lumen tube, & postop pain management
33
An esophagectomy is when
the majority of thoracic esophagus and nearby lymph nodes are removed, stomach is moved up and attached to the remaining portion of the esophagus
34
The surgical approach for an esophagectomy includes
RSI b/c the esophagus is being removed
depends on patient condition, portion to be removed, surgeon skill/preference
Pt's should be given gastrokinetics such as Reglan & avoid over-sedation preoperatively
Very sick patients- malnourished, pulm complications, wheezing, dyspnea
35
Complications of esophagectomy include
vocal cord paralysis, vocal cord palsy, wound infection, risk for fire
36
Gastrostomy is indicated for
dysphagia, high risk or active aspiration
37
Gastrostomy is when
an opening is created through the skin and the stomach wall to provide nutritional support or GI compression
38
The approach & anesthesia type for a gastrostomy is
laparoscopic, percutaneous (PEG) or open
surgical time < 1 hour
Anesthesia type: GA (RSI) or LA + sedation
39
A total gastrectomy is performed for
lesions in the upper 1/3rd of the stomach
40
A partial gastrectomy is performed for lesions in
the lower 2/3rd of the stomach
41
Anesthetic considerations for gastrectomy include
```
stable or acutely ill/malnourished
correct hypovolemia & anemia
chemo/radiation
cross matched blood available
full stomach/NGT
invasive monitoring
warming
Extubate- needs to be smooth (fully awake)
```
42
Complications of gastrectomy include
hemorrhage, peritonitis, PE, pneumothorax, anticipate fluid shifts
43
Intestinal surgery is performed for
diverticulitis, cancer, Crohn's disease, and ulcerative colitis
44
Intestinal surgery includes
small bowel resection, colectomy, colonoscopy
45
For patient's undergoing intestinal surgery, they will have a
bowel prep and might be dry, hypovolemic, & have electrolyte disturbances
46
Indications for a small bowel resection include
obstruction, cancer, diverticulum, Crohn's disease
47
A small bowel resection is when
healthy bowel is anastomosed or ileostomy created
48
Small bowel resection considerations
bowel prep (hypokalemia, hypovolemia), surgical time: 2-4 hours, EBL <500 mL, preop EKG, CBC, electrolytes, T&S
49
Postoperative complications for small bowel resection include
pulmonary effusion, anastomotic leak, short bowel syndrome, sepsis, small bowel necrosis
50
Anesthetic considerations for small bowel obstruction include
aspiration precautions, RSI with cricoid pressure if obstruction is present, NG tube, foley catheter, avoid metoclopramide, consider epidural for postop pain management, large third space fluid loss (10-15 mL/kg/hr), hypothermia
51
A colectomy is the
removal of part/all of the colon
| can be open or laparoscopic
52
Considerations with colectomy include
```
bowel preparation
clear liquids 1 to 2 days preoperatively
volume & electrolyte depleted
preoperative electrolytes
IV/PO antibiotics Preop
thoracic epidural for postop pain
corticosteroid supplements
```
53
The liver is highly vascular and total blood flow is
1.5 L/min
80% blood flow supplied by portal vein
20% hepatic artery
54
The liver is the only organ
capable of regenerating functional parenchyma within 24 hours of resection
-70% total liver mass can be regenerated in animal models
55
The liver has
metabolic and hematologic roles
| four lobes: left, right, quadrate, caudate or eight segments
56
Preop H&P for liver resection includes
bruising, anorexia or weight changes, N/V or pain with fatty meals, pruritus or fatigue, abdominal distension/ascites, GI bleeding, scleral icterus, hepatomegaly or splenomegaly, palmar erythema, gynecomastia, asterixis, spider angiomata, petechiae, & ecchymosis
57
Preop workup for a liver resection includes
CT or MRI for tumor location, 12-lead EKG/echocardiogram, CXR
lab studies: CBC, PT/PTT/bleeding time, chemistry profile, LFTs
58
Optimization of the liver resection patient includes
correction of ETOH dependency, coagulopathy, pH, electrolyte abnormalities (esp K+), malnutrition, anemia, esophageal varices, & hepatic encephalopathy
59
For patients undergoing liver resection, we assume
full stomach (ascites, decreased gastric & intestinal motility)- H-2 receptor blocker, metoclopramide, sodium citrate
60
In regards to sedative pre-medication for the liver resection patient,
titrate to effect, altered pharmacodynamics or pharmacokinetics
61
In regards to PT or INR & platelets for the liver resection platelet,
consider platelet infusion if <100,000 cells/microliter
| PT or INR- parental Vitamin K, recombinant factor VII (FFP in emergency)
62
Monitoring for patients with liver resections include
base decisions of severity of liver disease and type of surgery
2 LARGE BORE IVS- all but the most minor procedures b/c blood loss is unpredictable
A-line- BP & lab data
TEG to guide blood product administration
Foley catheter
OGT/NGT- be careful
TEE? (risky)
+/- CVP or PA (if pHTN)-multiple complex hemodynamic abnormalities
63
CVP or PA can be used in liver resections to assess
hypovolemia, abdominal compartment syndrome, distributive shock, CHF
64
For liver resection patients, benzodiazepines have
increased cerebral uptake
decreased clearance
prolonged half-life
65
For liver resection patients, dexmedetomidine has
decreased clearance and prolonged half-life
66
For liver resection patients, propofol has
longer recovery times after infusions
drug of choice with encephalopathy
single dose= similar response as normal patients
67
For liver resection patients, etomidate, ketamine, and methohexital have
unchanged elimination half-life in most studies
68
Intraoperative management of the liver resection patient includes
GETA- RSI or awake intubation- sevoflurane/isoflurane are agents of choice
fluids- no evidence colloids are better than crystalloids for resuscitation
altered pharmacokinetics
consider epidural for postop pain control
local/MAC- adequate sedation is essential to minimize SNS stimulation & resultant decreases in hepatic flow & O2 delivery- titrate carefully
69
NMB and liver disease causes
increased volume of distribution that may require a higher initial dose
cirrhosis/advanced liver disease prolongs elimination of vec, roc, panc, and mivacurium= increased DOA
cisatricurium & atricurium are not dependent on hepatic elimination and can be used without adjustment
70
Succinylcholine & liver disease
decreased cholinesterase levels,
| succinylcholine effects may be prolonged
71
Morphine & liver disease
prolonged half-life, exaggerated sedative & respiratory-depressant effects
72
Meperidine & liver disease
may experience neuro-toxicity from accumulation of normeperidine
73
Fentanyl and liver disease
plasma clearance is decreased- exaggerated effects
74
Remifentanil & liver disease
elimination unaltered
75
Alfentanil & liver disease
elimination half-life doubled--> enhanced effects
76
Intraoperative fluid management for the liver patient includes
limiting fluid pre-resection--> CVP < 5 cmH2O increases risk of venous air embolism
Portal triad clamping
post-resection- restore to euvolemia
volume loading--> distension of vessels with difficulty controlling blood loss
77
Patients with biliary obstruction are
particularly intolerant of blood loss
78
For hypotensive liver patients, consider
increased doses or addition of non adrenergic vasoconstrictor (vasopressin) to support BP
79
For patients with liver disease, there is an impaired ability to translocate
blood from pulmonary and splanchnic blood reservoirs to systemic circulation
80
For liver disease patients, there is a decreased response to catecholamines because
of circulating vasodilators such as bile acids & glucagon
81
Intraoperative complications of liver resection include
```
hemorrhage, coagulopathy
hypocalcemia
hypoglycemia
VAE
pulmonary disturbances
```
82
Post-operative complications of liver resection include
bleeding, bile leak, portal vein/hepatic artery thrombosis, liver failure
83
The spleen is part of the
lymphatic system
filters foreign substances from the blood and removes blood cells
regulates blood flow to the liver and sometimes stores blood cells (sequestration)- healthy adults 30% of platelets are sequestered in the spleen
84
The spleen is a highly
vascular organ of 300mL/min
85
Preop anesthetic considerations for splenectomy include
evaluate underlying disease process and implications
| chemotherapy & ITP
86
Intraoperative anesthetic considerations for splenectomy include
asepsis, large-bore venous access, warming measures, epidural for post-op pain
87
Complications of splenectomy include
atelectasis, pneumothorax, infection, hemorrhage & VAE
88
Splenectomy is the only treatment for
hereditary spherocystosis and cancers of spleen
other indications for removal: trauma, abscesses, idiopathic thrombocytopenic purpura, Hodgkin's staging, splenic artery rupture (pregnancy)
89
Bariatric surgery is reserved for patients with
BMI >40 kg/m2
| BMI >35 kg/m2 with related comorbidities not well controlled by medical therapy
90
The greatest cause of perioperative 30 day mortality for bariatric surgery is
pulmonary emobli
91
Bariatric surgery is a
surgical alteration of the small intestine or stomach to promote weight loss
92
Bariatric surgery types include
malabsorptive procedures: jejuno-ileal bypass and biliopancreatic diversion
restrictive procedures: gastroplasty (VBG) and adjustable gastric banding (AGB)
combined restrictive and minimal malabsorptive Roux-en-Y gastric bypass
93
Advantages to laparoscopic bariatric surgery include
less postop pain, lower morbidity, faster recovery, less fluid 3rd spacing, decreased wound infection, and smaller incisions
94
Disadvantages to laparoscopic bariatric surgery include
complete NMB is important, positioning requirements increase fall risk, high risk for right main-stem intubation (d/t diaphragmatic shift), incidence of rhabdomyolysis in obese pts higher compared with open procedure
95
For patients undergoing laparoscopic bariatric surgery, the anesthetists may need to
facilitate the proper placement of an intragastric balloon
prior to gastric diversion, ensure all endogastric devices are removed (avoid stapling in place or transection)
after gastric pouch in place, avoid blind NG insertion
96
Preoperative considerations of the obese patient include
DVT prophylaxis--> encourage early ambulation
airway assessment= neck circumference most important factor
OSA/OHS increase risk difficult airway- consider preop ABG
IM injections unreliable- thickness overlying adipose tissue
pre-medications- anxiolysis and aspiration pneumonitis precautions
97
Anesthetic considerations for the implantable gastric stimulator include
avoid N& V
valsalva may dislodge electrodes
ECG interference
98
Implantable gastric stimulator is supposed to
make patient feel less hungry
stimulate gastric smooth muscle, decrease peristalsis
SQ electric pulse generator implanted on abdominal wall
2 lead electrodes on greater curvature of stomach
99
Monitoring considerations of the obese patient include
monitors- appropriate sized BP cuff (forearm measurements overestimates BP)
IV & arterial line access may be challenging
Consider CVP or PAP catheter- significant CV or pulm disease or when large fluid shifts are expected
100
Positioning considerations of the obese patient include
Regular OR table max weight~~200 kg
high incidence of pressure sores and nerve injuries
"stacking" or "ramped" position for intubation to align ear with sternum
101
The most important induction consideration for the obese patient is
pre-oxygenation= most important step
| -decreased FRC, increased O2 consumption, +/- higher incidence of difficult airway
102
Induction considerations for the obese patient includes
induction drug dosing altered, consider awake intubation with minimal sedative-hypnotics, RSI?, may need two person mask ventilation/extra help, breath sounds may be difficult to auscultate, PEEP can be helpful intraop, routine use of reverse trendelenburg
103
Prevention of thromboembolism for the obese patient includes
LMW heparin- limits postop pain management options
preop aspirin & warfarin to INR 2.3
Decreased the risk via preoperative exercise, antithrombotic drugs, stocking prophylaxis, nonpolycythemic Hct, increased CO, early ambulation
104
The intraoperative fluid balance for obese patients takes into consideration that
they experience greater blood loss compared with non-obese patients secondary to technical difficulties/need for extensive dissection
105
For obese patients, there is a risk of
acute tubular necrosis with inadequate fluid replacement in bariatric surgery
106
There is a decreased ability to compensate for blood loss in obese patients and thus,
there is early threshold for replacement with colloids/blood products
107
For placement of regional anesthesia in obese patients, ____ & _____ has been used
ultrasound & fluoroscopy
108
Local anesthetic doses in the obese patient are
reduced by 20-25% due to epidural vascular engorgement and decreased epidural space
109
The subarachnoid block height in obese patients can be
unpredictable- high spinal is possible
110
For regional anesthesia in obese patients,
avoidance of intubation challenges vs. technically challenging landmark ID should be weight
central neuraxial blockade easier in lumbar region
longer needles may be required
111
Postop pain management for the obese patient includes
epidural anesthesia
PCA with opioid (multi-modal w/ opioid sparing should be attempted)
LA infiltration of incisicion site
non-opioid analgesics/adjuvants
obesity risk factor for postop hypoxemia- consider monitored bed/ICU+ CPAP postop, semi-recumbent position for first 48-72 hours
