Week 15 Handout Flipped Classrooms: Appendectomy

Question 1

What is an appendectomy?

Answer 1

Surgical removal of the appendix due to acute appendicitis.

Question 2

What are the types of appendectomy?

Answer 2

Can be laparoscopic (preferred) or open.

Question 3

What type of anesthesia is required for an appendectomy?

Answer 3

Requires general anesthesia—most commonly with RSI due to aspiration risk.

Question 4

What is the typical duration of an appendectomy?

Answer 4

30–90 minutes.

Question 5

What is the lifetime incidence of appendectomy?

Answer 5

Common Surgery: ~7% lifetime incidence.

Question 6

In which age group is appendectomy most frequent?

Answer 6

Most frequent in ages 10–30.

Question 7

Is appendectomy more common in males or females?

Answer 7

Slightly more common in males.

Question 8

What increases the risk of appendicitis?

Answer 8

Family history increases risk.

Question 9

How common is appendectomy in pregnancy?

Answer 9

One of the most common non-obstetric surgeries in pregnancy.

Question 10

What labs are required for preoperative preparation?

Answer 10

CBC, Renal panel, Pregnancy test, Type & screen.

Question 11

What is the antibiotic prophylaxis for appendectomy?

Answer 11

Cefazolin 1–2 g within 60 minutes of incision.

Question 12

What is the IV fluid resuscitation for appendectomy?

Answer 12

Address hypovolemia from fever, vomiting, poor intake.

Question 13

What antiemetics are used preoperatively?

Answer 13

Dexamethasone 4–8 mg, Aprepitant 40 mg (for severe PONV history).

Question 14

What is the preoperative acetaminophen dosage?

Answer 14

1000 mg as part of ERAS protocols.

Question 15

What is the positioning for laparoscopic appendectomy?

Answer 15

Supine with left arm tucked; table may be tilted left.

Question 16

What is the positioning for open appendectomy?

Answer 16

Often supine or left-tilted Trendelenburg.

Question 17

What is the aspiration risk during induction for appendectomy?

Answer 17

Acute appendectomy -> patient may have a full stomach = aspiration risk is high → RSI + cricoid pressure required.

Question 18

What induction drugs are used for appendectomy?

Answer 18

Etomidate 0.1–0.4 mg/kg or Propofol 1.5–3 mg/kg, Succinylcholine 1.5 mg/kg.

Question 19

What are the effects of CO₂ insufflation?

Answer 19

Increased intraabdominal pressure → Hypotension, Bradycardia, ↓ tidal volumes.

Question 20

How should you treat CO₂ insufflation effects?

Answer 20

Treat with vasopressors, anticholinergics, or request reduced insufflation.

Question 21

What is a potential complication during appendix manipulation?

Answer 21

Vagal stimulation possible d/t traction on peritoneum → bradycardia.

Question 22

What should be done for hypovolemic/pre-op dehydration?

Answer 22

Rehydrate before induction.

Question 23

What is the maintenance fluid rate?

Answer 23

3–5 mL/kg/hr.

Question 24

How should estimated blood loss (EBL) be managed?

Answer 24

EBL <75 mL, replace with crystalloids 3:1 ratio.

FOOTNOTE**
For every 1 mL of blood lost, you replace it with 3 mL of isotonic crystalloid solution (e.g., Lactated Ringer’s or Normal Saline).

Question 25

When should extubation occur?

Answer 25

Only extubate when patient is fully awake and laryngeal protective reflexes returned & are intact.

Question 26

What should be monitored during emergence?

Answer 26

PONV, Laryngospasm, Hemodynamic instability, Bleeding.

Question 27

What is TIVA in anesthesia?

Answer 27

Reduces PONV, suitable for sensitive patients.

Question 28

When is neuraxial anesthesia used?

Answer 28

Rare, but possible in patients with severe pulmonary disease that can't tolerate general.

Question 29

What is the sensory level block required for neuraxial anesthesia?

Answer 29

Requires T6–T8 sensory level block.

Question 30

What is a key takeaway regarding the type of surgery?

Answer 30

Appendectomy – most often laparoscopic.

Question 31

What is a key takeaway regarding anesthesia?

Answer 31

General with RSI due to aspiration risk.

Question 32

What are key patient risks during appendectomy?

Answer 32

Hypovolemia, full stomach, PONV.

Question 33

What should be monitored during surgery?

Answer 33

CO₂ insufflation effects, vagal response, hemodynamic shifts.

Question 34

What is a key takeaway for fluid management?

Answer 34

Aggressive hydration pre-induction.

Question 35

What is the 4-2-1 rule?

Answer 35

For every 1 mL of blood lost, you replace it with 3 mL of isotonic crystalloid solution.

Question 36

What is a key takeaway for emergence?

Answer 36

Extubate awake with airway reflexes intact.

Question 37

What are alternatives to general anesthesia?

Answer 37

TIVA or neuraxial (T6–T8 block) for specific cases.

Question 38

What are the risks associated with a perforated appendix?

Answer 38

Sepsis, hypotension, and hemodynamic instability.

Question 39

Student Question: What is another name for the RLQ incision made during an open appendectomy case? A. Trocar incision B. McBurney incision C. Brooke incision D. Kocher incision

Answer 39

Answer: B Rationale: McBurney incision is a surgical incision made in the right lower quadrant, commonly used for open appendectomy cases. Through this incision, the cecum is exposed and subsequently pulled into the open wound. The appendix is then brought through the wound and ligated (Jaffe et al., 2019).

Question 40

Student Question: Which of the following is the correct amount of hourly IV crystalloid fluid administration necessary to compensate for evaporative losses: either open or laparoscopic appendectomy? A. 1-2 mL/kg/hr B. 7-8 mL/kg/hr C. 3-5 mL/kg/hr D. 10 mL/kg/hr

Answer 40

Answer: C Rationale: For both open appendectomy, and laparoscopic appendectomy, standard of care is to have at least one 16-18 gauge IV for crystalloid administration. These crystalloids should be run at 5-8 mL/kg/hr for the duration of the case. Many patients will come in dehydrated from vomiting, lack of PO intake. This fluid deficit should be corrected as well, but that is a separate calculation that should be done and is not factored into the hourly fluid requirement to correct for evaporative losses (Jaffe et al., 2019).

Question 41

Student Question: Which of the following is the most common patient position during open or laparoscopic appendectomy? A. Supine to PTrendelenburg B.Prone C. Right lateral decubitus D. Seated

Answer 41

Answer: A Rationale: The most common patient position for open appendectomy is supine. In laparoscopic appendectomy cases, the patient is either placed in the supine position, or Trendelenburg with a slight left rotation to improve visualization of the right lower quadrant (Jaffe et al., 2019).

Question 42

Student Question: A patient is undergoing a laparoscopic appendectomy. After induction of anesthesia, the patient is positioned in Trendelenburg, and insufflation of the abdomen begins following trocar placement. Which of the following are potential respiratory and hemodynamic changes you might observe at this stage of the procedure? A. Bradycardia due to sympathetic stimulation B. Hypotension due to decreased intra-abdominal pressures C. Increased lung compliance and increased venous return D. Increased peak airway pressures, decreased venous return, bradycardia

Answer 42

Answer: D Rationale: During insufflation of the peritoneum, abdominal pressures increase substantially, pushing the diaphragm upwards. The shifting of the diaphragm can decrease lung compliance while increasing peak airway pressures. The increase abdominal pressure can also stimulate the vagus nerve, which could produce a vagal stimulation, resulting in bradycardia. Increased abdominal pressure will decrease venous return, resulting in hypotension to the patient (Jaffe et al., 2019).

Question 43

Student Question: A patient is undergoing laparoscopic appendectomy. The anesthetist knows that the normal estimated blood loss (EBL) for this type of surgery is <75mL. What is the appropriate amount of IV crystalloids the patient should receive to adequately replace this lost volume? A. 75 mL B. 150 mL C. 225 mL D.750 mL

Answer 43

Answer: C Rationale: Estimated blood loss for a laparoscopic appendectomy is typically at or less than 75 milliliters (Jaffe et al., 2019). Blood loss should be replaced at a 3:1 ratio when using crystalloids, therefore, to adequately replace the lost 75mL, 225 mL of crystalloids should be administered (Elisha et al., 2023).

Question 44

Student Question: A 28-year-old male presents for an emergent laparoscopic appendectomy due to acute appendicitis. Patient reports severe nausea, NPO status is unknown. Which of the following are the most appropriate steps the anesthesia provider should take during induction? [Select 2] A. Standard IV induction with positive-pressure bag mask ventilation before intubation B. Administration of anti-emetics such as metoclopramide to reduce aspiration risk C. Use of an LMA instead of endotracheal tube for airway D. RSI with cricoid pressure to reduce aspiration risk