Jaffegynecological8.1

Front 1

Laparotomy for Ovarian, Fallopian Tube, and Primary Peritoneal Cancer
Position:
Incision:

Back 1

Supine
Midline or paramedian abdominal

Front 2

Special instrumentation

Back 2

CUSA, Vital View (suction-irrigation device combined with light source) helpful; laparoscopic biopsy forceps (laparoscope, laparoscopic instruments for evaluation of upper abdomen through lower vertical abdominal incision); Argon beam coagulator (ABC); TA, GIA, EEA stapling devices.

Front 3

Unique considerations

Back 3

Removal of large amounts of ascites may → fluid shifts and intravascular volume depletion intraop and postop.

Front 4

Antibiotics
Surgical time

Back 4

Cefotetan 2 g iv; further doses as indicated by large EBL, duration of surgery.
1–4 h; 4–5 h, including splenectomy and bowel surgery for more advanced stages

Front 5

Closing considerations

Back 5

NG tube placement by anesthesiologist (in select cases with extensive bowel involvement or bowel procedures); peritoneal or central venous access for subsequent chemotherapy

Front 6

EBL

Back 6

500–1000 mL; 250–500 mL for Stage I lesions; > 1000 mL for more advanced stages

Front 7

Postop care

Back 7

Extensive peritoneal raw surfaces → intraperitoneal fluid 3rd-spacing. Patients require good hydration to maintain intravascular volume. Central hemodynamic monitoring and ICU admission are useful in selected patients. Use SCDs and mini-dose heparin for VTE prophylaxis.

Front 8

Mortality

Back 8

1–2/1000

Front 9

Morbidity

Back 9

Postop fever: 14–19%
Wound infection: < 5%
Wound dehiscence: 0.3–3%
PE: 1–2%
Ureteral injury: < 1%
Vaginal vault prolapse: Rare

Front 10

Pain score

Back 10

Pain score 7–8

Front 11

Age range

Back 11

All age groups; most common, 50–59 yr

Front 12

Incidence

Back 12

15/100,000 (26,700+ new cases/yr); 1.4% lifetime risk of ovarian cancer

Front 13

Anesthetic Considerations for Laparotomy for Ovarian, Fallopian Tube, and Primary Peritoneal Cancer

Back 13

anesthesia

Front 14

Respiratory
Significant ascites and pleural fluid may produce

Back 14

respiratory compromise

Front 15

Respiratory
investigate presence of

Back 15

dyspnea, orthopnea, tachypnea, or other chest findings

Front 16

Underlying lung diseases, such as asthma, also may be exacerbated by

Back 16

abdominal distension/ascites

Front 17

Tests:

Back 17

Consider CXR; others as indicated from H&P

Front 18

Cardiovascular
An ECHO or other studies may be requested to

Back 18

evaluate cardiac function.

Front 19

Cardiovascular
Exercise tolerance should be evaluated

Back 19

in every patient and any preexisting cardiac disease explored in the preop visit.

Front 20

Cardiovascular
Irreversible, dose-dependent cardiotoxicity may result from

Back 20

doxorubicin chemotherapy

Front 21

Cardiovascular
Tests:

Back 21

Consider ECG, others as indicated from H&P.

Front 22

Gastrointestinal
if given a bowel prep overnight.

Back 22

Patient should have adequate preop iv hydration

Front 23

gastro
Opiate use may cause

Back 23

↓GI motility. May be malnourished.

Front 24

Neurological Not usually significant. Taxol and cisplatin may cause→

Back 24

peripheral neuropathy.

Front 25

Hematologic
Bone marrow suppression common following

Back 25

chemotherapy.

Front 26

hematology
Carboplatin, commonly used for ovarian cancer,

Back 26

often induces thrombocytopenia.
Tests: CBC

Front 27

Laboratory

Back 27

CBC, hepatic function, PT/PTT, T & S or T & cross

Front 28

Premedication

Back 28

Consider midazolam 1–2 mg iv

Front 29

Intraoperative Laparotomy for Ovarian, Fallopian Tube, and Primary Peritoneal Cancer

Back 29

anesthesia

Front 30

Anesthetic technique:

Back 30

GETA ± epidural analgesia.
An epidural catheter may be placed for postop pain management and also may be used intraop to ↓ anesthetic requirements.

Front 31

Anesthetic technique description

Back 31

Typically, a balanced anesthetic with inhalational agents and/or propofol infusion (25–200 mcg/kg/min) and narcotics.

Front 32

Induction

Back 32

Standard induction (see p. B-2), though consider full stomach precautions if ascites present.

Front 33

Maintenance

Back 33

Standard maintenance
muscle relaxation based on nerve stimulator response.
Epidural 2% lidocaine with epinephrine 1:200,000 (~3–5 mL/h) if catheter is placed preop. Consider NG/OG tube.

Front 34

Patients with combined regional/GA may require

Back 34

increased fluids due to vasodilation and ↓BP.

Front 35

Emergence
The patient may be extubated at the conclusion of surgery, unless

Back 35

hemodynamically unstable and/or requiring continued vigorous fluid resuscitation.

Front 36

Emergence
Reverse muscle relaxant with

Back 36

neostigmine 0.07 mg/kg and glycopyrrolate 0.01 mg/kg, and give supplemental O2 after extubation.

Front 37

Consider postop ICU bed for

Back 37

unstable patients or those requiring invasive monitoring for fluid management.

Front 38

Blood and fluid requirements

Back 38

Significant blood loss possible

Front 39

IV:
NS/LR at
5% albumin
6% hetastarch

Back 39

16–18 ga × 2
4–6 mL/kg/h

Front 40

Blood loss may be > (≥10–15 mL/kg/h).

Back 40

1 L Order T & S or T & cross preop.

Front 41

5% albumin or 6% hetastarch are useful for

Back 41

rapid volume replacement if Hct is acceptable

Front 42

If large volumes of ascites are removed, significant

Back 42

↓BP may develop.

Front 43

Third-space losses may be

Back 43

. significant

Front 44

Consider alternating NS and LR to avoid

Back 44

development of a nonanion gap hyperchloremic acidosis 2° NS.
Warm fluids.

Front 45

Strive to maintain euvolemia based on clinical data:

Back 45

BP, HR, ABG, UO, EBL, and fluid shift estimates, ± CVP, etc.

Front 46

Monitoring Standard monitors ±

Back 46

Arterial catheter
± CVP catheter
Foley catheter

Front 47

Arterial and CVP catheters indicated for

Back 47

extensive surgery and/or patients with significant comorbidities (CHF, CAD, COPD, renal failure, etc).

Front 48

Positioning
pad

Back 48

pressure points, especially important for longer surgeries
eyes
Antiembolism stockings and SCDs

Front 49

Complications
Hypothermia likely to develop.
Prevent by:

Back 49

Warm all IV fluids. Heating blanket on bed and forced-air warming blanket should be used.

Front 50

Coagulopathy due to preop

Back 50

Preop malnutrition and/or significant blood loss may → coagulopathy

Front 51

Postoperative
Complications

Back 51

Hemorrhage
VTE
Ascites/pleural effusion
Respiratory insufficiency
PONV

Front 52

Pain management

Back 52

PCA
Epidural

Front 53

Epidural may ↓

Back 53

pain, PONV, and risk of VTE.

Front 54

Interval, Second-Look/Reassessment, and Secondary Cytoreductive Laparotomy for Ovarian Cancer

Back 54

Summary of Procedures

Front 55

Position

Back 55

Supine

Front 56

Incision

Back 56

Midline or paramedian vertical abdominal

Front 57

Antibiotics

Back 57

Cefotetan 2 g iv, then q 12 h × 2 doses

Front 58

Surgical time

Back 58

2–3 h

Front 59

Closing considerations

Back 59

Placement of permanent central venous or intraperitoneal access

Front 60

EBL

Back 60

350–700 mL

Front 61

Postop care

Back 61

PACU → ward

Front 62

Anesthetic Considerations

Back 62

Preoperative

Front 63

Respiratory
Pulmonary function may be impaired by several

Back 63

chemotherapeutic drugs, most commonly bleomycin.

Front 64

Respiratory
Patients often have a ? already in place, which can be used for induction of anesthesia.

Back 64

Hickman catheter or other central line

Front 65

Respiratory
Obtain preop CXR to assess the presence of

Back 65

lung injury if prior chemo given.

Front 66

Respiratory
Patients who have dyspnea at rest or with mild exertion, or who have known pulmonary fibrosis, should be evaluated by

Back 66

PFTs, including FVC, FEV1, MMEF25–75, and ABGs.

Front 67

Respiratory
Patients who have received bleomycin should not receive

Back 67

O2 > 39% intraop, but arterial O2 saturation ideally should be kept ≥ 93%.

Front 68

Respiratory
The pulmonary toxicity of bleomycin is

Back 68

dose-related with a much higher incidence occurring if > 200 mg/m2.

Front 69

Combination chemotherapy with vincristine or cisplatin also increases

Back 69

pulmonary toxicity.

Front 70

Postop mechanical ventilation may

Back 70

be necessary.

Front 71

Tests: Consider

Back 71

CXR; others as indicated from H&P.

Front 72

Cardiovascular
Cardiotoxicity is seen with several antineoplastic agents, especially

Back 72

daunorubicin and doxorubicin.

Front 73

Cardiovascular
The cardiomyopathy produced by these drugs occurs in two forms:

Back 73

(1) acute—ST-T wave changes and dysrhythmias, which are transient and usually not a serious problem; and (2) chronic—a dose-related toxicity manifested by CHF.

Front 74

Cardiovascular
Total doses of doxorubicin as low as 250 U can cause myocardial damage, but is more common at doses

Back 74

> 400 U.

Front 75

Cardiovascular
Cardiac irradiation, or combination chemotherapy with ? increases the risk of cardiac toxicity.

Back 75

cyclophosphamide,

Front 76

Cardiovascular
Patients who have received cardiotoxic drugs are usually followed by serial

Back 76

ECHOs or MUGA scans, and the results of these tests should be reviewed preop.

Front 77

Cardiovascular
Patients with CHF or ECG changes should have

Back 77

a cardiology consultation preop to optimize their medical condition.

Front 78

cardio
Tests:

Back 78

ECG; others as indicated from H&P.

Front 79

Neurological
Peripheral neuropathies are produced by

Back 79

vincristine, cyclophosphamide, Taxol (paclitaxel), 5-fluorouracil and several other drugs.

Front 80

Neurological
Vincristine can also cause → .

Back 80

SIADH

Front 81

Neurological
Other CNS effects include

Back 81

N/V, Seizure, and cerebellar dysfunction.

Front 82

Neurological
A preop neurologic exam is useful for

Back 82

patients with evidence of neurotoxicity.

Front 83

Neurological
Document presence of neurologic

Back 83

deficits preop for subsequent comparisons.

Front 84

Endocrine
Corticosteroids (e.g. prednisone) are commonly used with chemotherapeutic agents, as treatment for

Back 84

for pulmonary fibrosis and other complications of chemotherapy.

Front 85

Endocrine
The use of steroids for several weeks suppresses the

Back 85

endogenous secretion of the adrenal cortex, which may take up to 6 mo to recover fully.

Front 86

Endocrine
Hydrocortisone 100 mg iv, preop with an additional 2–3 subsequent doses q 8 h will provide

Back 86

adequate “stress dose” coverage perioperatively.

Front 87

Endocrine
The hydrocortisone dose is tapered rapidly over

Back 87

2 or 3 d postop.

Front 88

Endocrine
Tests:

Back 88

As indicated by the H&P.

Front 89

Renal
Many chemotherapeutic drugs have renal toxicity; therefore, a

Back 89

preop set of renal function tests is mandatory.

Front 90

Renal
Patients with impaired renal function should be given appropriate dosages of

Back 90

medications (e.g., antibiotics), which depend on renal excretion.

Front 91

Renal
Tests:

Back 91

Renal function tests

Front 92

Musculoskeletal
Vincristine produces a neurotoxicity manifested by .

Back 92

numbness and tingling in the extremities, weakness, foot drop, loss of reflexes, ataxia, and muscle pains.

Front 93

Musculoskeletal
Muscle weakness in the arms and legs indicates that Vincristine should be

Back 93

stopped

Front 94

Musculoskeletal
Muscle weakness with Vincristine may also involve the

Back 94

larynx and extraocular eye muscles.

Front 95

Musculoskeletal
??? amounts of NMBs should be used intraop and a nerve stimulator used to follow twitches.

Back 95

Reduced

Front 96

Gastrointestinal
Consider ??? overnight if pt given a bowel prep or if there is significant N/V.

Back 96

hydration

Front 97

Gastrointestinal
Tests:

Back 97

Consider serum electrolytes, if indicated from H&P.

Front 98

Hematologic
Bone marrow suppression is a very common side effect of Consider preop transfusion of Plts and/or RBCs if lab values are below acceptable limits (Plt < 75,000, Hct < 25%).
Tests: Hemogram, WBC, Plt, PT/PTT

Back 98

antineoplastic drugs.

Front 99

Hematologic
The toxicity usually produces a reversible drop in

Back 99

leukocytes, erythrocytes, and platelets, with a nadir 10–14 d posttreatment.

Front 100

Hematologic
Patients with a total neutrophil count of <

Back 100

1,000 should be kept in isolation until counts improve.

Front 101

Hematologic
A low Plt count (< 75,000) is an indication for

Back 101

Plt transfusion preop.

Front 102

Regional anesthesia in patients with thrombocytopenia needs to be considered carefully due to

Back 102

↑ risk of bleeding complications.

Front 103

It is useful to check preop ??? when in doubt about the coag status of a patient.

Back 103

[check mark]PT/PTT

Front 104

Laboratory

Back 104

LFTs if indicated by H&P.

Front 105

Premedication

Back 105

Consider midazolam 1–2 mg iv. Stress-dose hydrocortisone (100 mg iv) if indicated.

Front 106

Interval, Second-Look/Reassessment, and Secondary Cytoreductive Laparotomy for Ovarian Cancer
Intraoperative
Anesthetic technique

Back 106

anesthesia

Front 107

Intraoperative
Anesthetic technique

Back 107

GETA usually indicated. Combined GETA/epidural or spinal are also excellent choices.

Front 108

Consider surgery under regional anesthesia in patients with severe

Back 108

bleomycin pulmonary toxicity.

Front 109

General anesthesia:
Induction

Back 109

Standard induction (see p. B-2). Consider renal function and surgery duration when deciding on agents.

Front 110

Maintenance

Back 110

Standard maintenance:

Front 111

An epidural may be used to reduce

Back 111

GA requirements
Consider NGT/OGT.

Front 112

Emergence
Extubate when patient is Consider PONV prophylaxis (see p. B-6).

Back 112

responsive and neuromuscular block is fully reversed.

Front 113

In patients with borderline pulmonary function, extubation may be delayed until patient is in the

Back 113

PACU or ICU, and after ABG is checked while the patient breathes spontaneously.

Front 114

Regional anesthesia:
Epidural dose?

Back 114

2% lidocaine ± epinephrine 1:200,000 (10–20 mL) or 0.25% bupivacaine (10–20 mL) initially; then at ~3–5 mL/h.

Front 115

Narcotics, such as ?? may be given in the epidural for postop pain control.

Back 115

morphine (2–4 mg) or hydromorphone (0.3–0.6 mg),

Front 116

Blood and fluid requirements IV:
NS/LR at

Back 116

16–18 ga × 1–2
7–10 mL/kg/h

Front 117

Keep UO >
Consider PRBC for Hct <

Back 117

0.5 mL/kg/h
27%

Front 118

Excessive use of NS can lead to ?? therefore, alternating NS and LR solutions makes sense when giving large volumes of iv fluids.

Back 118

hyperchloremic metabolic acidosis;

Front 119

5% albumin
6% hetastarch may be used as

Back 119

volume replacement, although no proven advantages over crystalloid solutions.

Front 120

Consider FFP and Plt if evidence of .

Back 120

coagulopathy (↑PT, ↑PTT, ↓Plt)

Front 121

Monitors/ standard but also ± (3)

Back 121

± Arterial line
± CVP catheter
Foley catheter

Front 122

Consider Arterial and CVP catheters for patients with

Back 122

compromised cardiac or pulmonary function or patients having extensive surgical procedures.

Front 123

Positioning/protection

Back 123

check mark]and pad pressure points
[check mark]eyes
Anti-embolism stockings and SCD

Front 124

Complications

(2)

Back 124

Hypothermia Warm fluids; keep heating pad on bed; use forced-air warmer
Bleeding [check mark]PT; PTT, Plts periodically if large blood loss

Front 125

Blood and fluid requirements IV:
NS/LR at

Back 125

16–18 ga × 1–2
7–10 mL/kg/h

Front 126

Keep UO >
Consider PRBC for Hct <

Back 126

0.5 mL/kg/h
27%

Front 127

Excessive use of NS can lead to ?? therefore, alternating NS and LR solutions makes sense when giving large volumes of iv fluids.

Back 127

hyperchloremic metabolic acidosis;

Front 128

5% albumin
6% hetastarch may be used as

Back 128

volume replacement, although no proven advantages over crystalloid solutions.

Front 129

Consider FFP and Plt if evidence of .

Back 129

coagulopathy (↑PT, ↑PTT, ↓Plt)

Front 130

Monitors/ standard but also ± (3)

Back 130

± Arterial line
± CVP catheter
Foley catheter

Front 131

Consider Arterial and CVP catheters for patients with

Back 131

compromised cardiac or pulmonary function or patients having extensive surgical procedures.

Front 132

Positioning/protection

Back 132

check mark]and pad pressure points
[check mark]eyes
Anti-embolism stockings and SCD

Front 133

Complications

(2)

Back 133

Hypothermia Warm fluids; keep heating pad on bed; use forced-air warmer
Bleeding [check mark]PT; PTT, Plts periodically if large blood loss

Front 134

Postoperative
Complications

Back 134

Bleeding
PONV
Infection
Respiratory insufficiency
VTE

Front 135

Pain management

Back 135

PCA
Epidural/spinal narcotics

Front 136

Surgeons may infiltrate wound edges with ?? in those patients without epidurals.
Consider iv

Back 136

0.25% bupivacaine
ketorolac (30 mg)

Front 137

Tests

Back 137

CXR
ABG As indicated by postop clinical findings.