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172 Cards in this Set
- Front
- Back
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trocar insertion puts pt at risk for what?
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major organ or vessel entry-hemorrhage or peritonitis
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what can electrofulguration or cautery cause?
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bowel burns
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what is electrofulguration useful for?
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dissection and endometriosis
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what occurs with gas insufflation?
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-increase in intrabdominal pressure
-interferes with normal ventilation and oxygenation d/t pressure on diaphragm -hypercapnia -impaired venous return -increased aspiration risk |
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gas insufflation interferes with normal ventilation and oxygenation d/t pressure on diaphragm causing what?
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-reduced pulm compliance by 30-50%
-reduced FRC -VQ changes |
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why does hypercapnia occur with gas insufflation?
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d/t absorption and from impaired ventilation
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what are complications of gas insufflation?
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-subcutaneous emphysema
-pneumothorax, pneumomediastinum, pneumopericardium -endobronchial intubation -gas embolism |
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subq emphysema is from what?
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extraperitoneal insufflation
-will see cont increase in ETCo2 |
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how does pneumothroax etc occur with gas insufflation?
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-via defects in diaphgram, aorta, or esophagus
-pleural tears -bullae rupture -reduces airway compliance, increase pressure -increases EtCO2 w/ gas absorption |
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what do you see with bullae rupture?
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reduction in end-tidal carbon dioxide
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what is tx for pneumothorax, pneumomediastinum, etc?
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-stop N2O
-adjust vent settings to correct hypoxemia -PEEP (xcept in bullae rupture) -reduce intraabd pressure -comm. w/ surgeon -usually resolve spont. unless rupture of lung tissue has occured ( need chest tube) |
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how does endobronchial intubation occur?
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cephalad mvt of carina after insufflation
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what do you see w/ endobronchial intubation?
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-decreased O2 sat
-increased airway pressure |
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what is the most feared and dangerous complication of gas insufflation?
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gas embolism
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when does a gas embolism occur?
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-either by direct injection through trocar or needle
-or by insufflation of gas |
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what should rate of insufflation be?
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<1L/min
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why is CO2 used?
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-more soluble than O2, air, or N2O
-carrying capacity in blood high d/t bicarbonate buffering and combination w/ hgb and plasma proteins -rapid elimination increases margin of safety |
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what occurs with a gas lock in vena cava and right atrium?
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-obstructs venous return
-reduced CO -paradoxical gas embolism if patent FO -increased dead space ventilation and hypoxemia |
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how is gas embolism diagnosed?
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-change in doppler
-increased PAP -at 2ml/kg see tachy, dsyrhythmias,hypotension, increased CVP, alt. heart tones, ECG changes, pulm edema -reduced ETCO2 d/t decreased CO and increased dead space -aspiration of gas or foamy blood from CVP |
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what is treatment of gas embolism?
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-stop insufflation
-left side down, head down, -100% oxygen -no N2O -hyperventilation -CVP or PA to try and evacuate air -CPR or bypass if needed |
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what are some possible causes for increased N/V risk in laprascopic surgeries?
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-young
-female -gas pressure on gut -true cause unknown |
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what should plan for antiemetic?
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-ondansetron
-hydration -metoclopramide -dexamethasone -OG to empty stomach |
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if pt has history N/V what should you do?
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-avoid inhalation agents/nitrous oxide
-diprivan gtt -use adjunct agents to reduce amt of narcotics ex toradol |
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what is anesthetic managment for laprascopic abd surgeries?
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-GA required
-muscle relaxation or adequately deep anesthesia -consider lg bore IV -antiemetics and/or empty stomach |
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what are third space losses for minimal trauma?
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2-4ml/kg/hr
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what are moderate third space losses?
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6ml/kg/hr
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what are major trauma third space losses?
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8-10ml/kg/hr
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mobilizaiton of surgical fluid will occur on what day?
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third post-op day
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what are maintenance fluid needs?
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about 40ml + wt in Kg
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how do you calculate fluid deficeit?
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maintenance x hrs NPO divided over 3 hrs
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what are pros of colloids?
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-stays in intravascular space T1/2: 3-6hrs
-rapid replacement with smaller volume -less edema -decrease ICP |
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what are cons of colloids?
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-expense
-coagulopathies -allergic reactions etc -ARDS-CHF-Pulm edema -decrease GFR d/t increase tubular flow into kidneys |
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what are cystalloid pros?
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-cheap
-no allergic rxns -readily available -replaces interstitial fluid well -easy -works quickly-increase GFR |
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what are crystalloid cons?
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-don't stay in intravascular space very long T1/2=20-30min
-hemodilution -electrolyte shifts -pulm edema -hemodynamic changes are short lived |
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what is hespan limit?
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20ml/kg/day
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what is fluid status on pt having abd surg?
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-history of fluid losses d/t bowel prep
-GI bleed -diarrhea -Fever -fluid sequestration in bowel -emesis or gastric drainage |
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what are s/s of hypovolemia/fluid assessment?
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-tachycardia
-orthostatic changes -hypotension -dry mouth and decreased skin turgor -cool mottled skin -resp variation on ECG -increase in HCT and BUn elevations |
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what are seen with large GI losses?
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-hypokalemia and metabolic alkalosis
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metabolic acidosis is seen with what?
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diarrhea and septicemia
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pts with liver disease can have what that affect hematologic system?
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coagulopathies
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regional anesth is suitable for what kind of abd surg?
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lower abd surgery only
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why is general anesthesia technqiue most common for abd surg?
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-can protect airway and ventilate
-able to control depth and duration of anesthesia |
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choice of anesthetic is dependent upon what?
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-duration
-surgeon preference -patient preference -type of surgery |
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what types of cases or pt need RSI?
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-trauma or other emergent cases
-bowel obstruction -hiatal hernia -2nd or 3rd trimester of preg (or 6wks post partum) -obesity -ascites, diabetics and renal pts |
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what may be some pretreatments for RSI?
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-bicitra
-ranitidine -metoclopramide |
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what is sequence of RSI?
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-pretreatment
-preoxygenate fully -rapid delivery of indxn agents plus succs -sellick's maneuver -intubate |
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what does bicitra do?
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-decrease acidity in gut, but increase in volume
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what does ranitidine do?
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decrease amt of acid, doesn't decrease acidity of what is already in stomach
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what does metoclopramide do?
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helps empty stomach
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what is mendelson syndrome?
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acid aspiration syndrome
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what results from acid aspiration syndrome?
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atelectasis
alveolar edema loss of surfactant |
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what are s/s of mendelson syndrome?
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-hypoxia
-wheezing -tachycardia and tachypnea -hypotension -ABG alterations (decrease PaO2, increase PaCO2, acidosis |
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there is an increased risk with volume of aspirate greater than ____cc and pH less than ___?
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-25cc
-ph<2.5 |
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how do you reduce risk of mendelson syndrome?
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-accelerate gastric emptying
-increase gastric pH -increase lower esophageal sphincter tone -empty stomach |
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what is tx of acid aspiration?
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-head down
-suction mouth and trachea -PPV and PEEP -bronchoscopy, pulm lavage, antibiotics, steroids |
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when should you avoid nitrous?
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-on trauma pts
-on bowel obstructions |
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what can you do to help with pulmonary comprise when surgeon is using retractors?
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-add PEEP'
-increase tidal volume |
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what is radiation heat loss?
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heat radiates off body
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what is conduction heat loss?
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heat loss to surfaces
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what is convection heat loss?
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heat loss d/t air currents
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what is evaporation heat loss?
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fluid losses
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what is the biggest cause of heat loss?
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radiation
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what are the heat losses d/t GA?
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-OR temps
-IV or irrigating fluids -dry anesthetic gases -expose of body surfaces and viscera |
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what are effects of hypothermia w/ anesthesia?
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-decreased BMR
-peripheral vasoconstriction -leftward shift of oxyhgb diss. curve -post-op shivering -poor blood coagulation -ineffective muscle relaxant reversal -poor wound healing |
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when can v-fib occur?
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occurs at temps below 94 degrees F
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what are the ways you can monitor temp during surg?
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-rectal
-esophageal -skin -bladder -nasopharyngeal -tympanic |
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how can you prevent heat loss?
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-warming blankets
-warm OR temp -warm fluids -blankets -low gas flows -warming fluids -hemofiltration devices -plastic wrap |
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how can you tx hiccups?
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-muscle relaxants
-deepen anesthetic -thorazine 5mg |
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what is BMI in obesity?
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>28/>30
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what is considered morbid obesity?
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>35
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what body shape is higher risk?
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truncal (android) obesity
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what increases with truncal obesity?
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-increased O2 consumption
-increased riskof CVD |
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because of increased O2 consumption what happens?
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-increased metabolic activity of fat
-increased locomotive energy -increased energy of breathing |
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what increases w. exercise in the obese?
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-oxygen consumption and CO2 production
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what happens to the FRC in the obese pt in upright position?
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decreased FRC and ERV
-TV falls w/in closing capacity -VQ mismatch -right to left shunt |
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how are pulmonary function tests affected in the obese pt?
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they are usually normal
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what is pickwickian syndrome?
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-extreme OHS
-increased ETCO2 -hypoxemia -polycythemia -hypersomnolence -pulm HTN -biventricular failure |
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what happens to cardiac system in obese pts?
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-increased blood volume, plasma volume and CO
-splanchnic blood flow increases -HTN -cardiomegaly -impaired systolic/diastolic function -increased pulm blood volume, increased pulm HTN |
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what happens to endocrine system in obese pts?
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-impaired glucose tolerance
-abnormal lipids |
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what happens to GI system in obese pts?
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-hiatal hernia
-increased intra-abd pressure -increased vol. and low pH of stomach contents -increased liver fat |
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why are obese pts difficult airways?
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-neck flexion limited by "chins" and chest wall fat
-fat pads -increased soft tissue -large tongue -submental fat -high incidence sleep apnea |
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what is distribution affected by?
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-increased CO
-increased Blood volume -lean body mass -organ size -fat mass |
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water soluble drugs have higher or smaller volume of distribution?
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smaller
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fat soluble drugs have smaller or larger volume of distribution?
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larger
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phase II are cleared slower or faster?
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faster
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what happens to GFR and tubular secretion?
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increased
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when is awake intubation recommended?
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if IBW >75%
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why is nitrous good in obese pts?
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not fat soluble
-may need >50% O2 to ventilate |
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why do you need to be careful w/ narcotics in obese pts?
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increased risk of CO2 and hypoxemia
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what areas of obese pts cause positioning concerns?
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-heels
-butt -shoulders |
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what makes Regional Anes,. difficult on obese pts?
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-need longer needles
-poor landmarks -spinal and epidural reduced to 75-80% of normal dose |
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what are obese pts at risk for post-op?
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-hypoxemia
-dVT -caution w/ PCA's |
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what are some other concerns w/ open choles?
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-increased cost
-longer hospitalizations -increased resp problems |
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what are the five F's of cholellithiasis?
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-female
-fat -forty -fertile -flatus |
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how can you tx shincter of oddi spasm?
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-NTG
-glucagon -narcan |
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when is glucagon contraindicated in tx of sphincter of oddi spasm?
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w/ pheochromocytoma
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what is pheochromocytoma?
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catecholamine secreting tumor
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where is pheo found?
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-chromaffin tissue in adrenal medulla
-right atrium -spleen -ovary -aorta -rarely via lymphatic to liver |
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what catecholamine is secreted greater w/ pheo tumors?
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NE>epi
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what are affects of alpha-1 stimulation?
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-increased pulm and systemic vascular resistance
-decreased intravascular volume -increased HCT -renal failure -cerebral hemorrhage -increased myocardial work -increased glucose level |
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how is dx of pheo made?
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by analyzing catecholamine levels in urine
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what is end product of catecholamine metabolites?
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VMA
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what is most sensitive indicator of pheo?
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24 hr NE in the urine
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what are the triad of symptoms in pheo?
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-diaphoresis
-tachycardia -HA |
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what is tx of pheo?
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tumor removal
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what is key to successful tx of pheo?
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alpha and beta antagonist therapy
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what is the alpha antagonist used to manage pts w/ pheo?
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phenoxybenzamine
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what is dose for phenoxybenzamine in 70kg pt?
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-20-30mg QD or bid up to 60-250mg/day
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how many days pre-op does a pt need to take phenoxybenzamine?
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10-14 days at least
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what are good agents intra op on pheo pts?
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regititine and esmolol
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what do you want the BP < pre-op?
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less than 160/90 x 2 36 hrs prior to surgery
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should have a BP drop greater than ____ with standing, but greater than ____?
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-greater than 15% but needs to be greater than 80/45
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what is necessary as adrenal tissue is removed?
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cortisol
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what meds do you need to avoid in pts with pheo?
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-avoid sympathomimetics
-no ketamine -no halothane |
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what muscle relaxants shoud be avoided?
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-succs
-pancuronium |
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what are useful anesthetic drugs in pts with pheo?
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-inhalation agents, including nitrous
-esmolol, regisitine -lidocaine -phenylephrine |
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what are some other medications that should be avoided in pts w/ pheo?
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-avoid histamine releasers
-avoid droperidol |
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what is a carcinoid tumor?
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-tumors found in various sites t/o the body
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where are carcinoid tumors usually found?
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in GI tract but also found in lungs and bronchi
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what are the vasoactive substances released from carcinoid tumor?
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-histamine
-serotonin -kallikreins -bradykinins |
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what does histamine release cause?
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-vasodilation
-bronchoconstriction -dysrythmias |
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what does serotonin cause?
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-vasoconstriction
-increased intestinal tone -electrolyte imbalances -inotropic and chronotropic effects |
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what do kallikreins cause?
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vasodilation
bronchoconstriction |
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what do bradykinins cause?
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hypotension
bronchoconstriction (minor effects compared to histamine, serotonin, andkallikreins |
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what are s/s of carcinoid syndrome?
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-bronchoconstriction
-tricuspic regur, pulmonic stenosis -dysrythmias -flushing or cyanosis -abd pain and diarrhea -hepatomegaly -hyperglycemia -decreased albumin -labile vital signs |
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how is diagnosis of carcinoid syndrome made?
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via metabolite in urine
--5-hydroxyindolacetic acid |
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what is anesthetic managment of carcinoid syndrome?
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-octreotide
-somatostatin -corticosteroids -anithistamines |
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what are some other anesthetic considerations in pts w/ carcinoid syndrome?
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-avoid hypotension
-avoid sympathetic NS stimulation -give volume -avoid histamine releasing agents |
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what are CV changes in the elderly?
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-decrease arterial elasticity
-increased afterload, SBP, LVH -myocardial fibrosis -decreased baroreceptor function -increased vagal tone -decreased sensitivity of adrenergic receptors -dysrythmias |
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what are pulm changes in elderly?
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-decreased elasticity
-increased RV adn closing capacity -increased chest wall rigidity -decreased muscle strength -blunted response to both hypercapnia and hypoxia |
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what are CNS changes in elderly?
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-cerebral blood flow and brain mass decrease
-perceptive changes -cognitive defects |
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what are renal changes in elderly?
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-renal blood flow and mass decrease
-decreased CrCl and GFR -impaired Na+ handling -increased risk of ARF |
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what are hepatic changes?
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-decreased hepatic blood flow and mass
-biotransformation rate and albumin production decrease -decreased plasma cholinesterase levels in men |
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why is pharmacology compromised in elderly?
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-decreased hepatic and renal functions
-changes in protein binding -decreased muscle mass, blood volume, and lean body mass |
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what are anesthetic considerations in the elderly?
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-decrease narcs by 50%
-care w/ moving and positioning -at risk for hypothermia -reduced drug needs |
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what kind of anes is used for cysto?
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-MAC, GA, deep sedation, SAB
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if use SAB in cysto what level do you need?
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T10
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if use SAB in cysto w/ retrograde what level block do you need?
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T6
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when would a transurethral resection of bladder be done?
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remove superficial bladder tumors
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what is preffered anesthetic preference for transurethral resection of bladder?
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GA--regional anes increases risk of bladder perforation
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what are risks of transurethral resection of bladder?
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-blood loss
-hypothermia -bacteremia -bladder perforation |
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what is peritoneal invasion in awake patient signaled by?
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-shoulder pain
-nausea -vomiting |
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if there is peritoneal invasion what are s/s see in pt under GA?
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-unexplained HTN
-tachycardia -rarely see hypotension |
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what can infusion of glycine cause?
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-hyperglycinemia
-hyperammonemia |
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what are s/s of hyperglycinemia?
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-circulatory depression/hypotension
-CNS toxicity -transient blindness |
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what are normal levels of ammonia in blood?
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5-50micromoles/L
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what can levels exceed in hyperammonemia?
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500
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what is preffered method of anesthesia for TURP?
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spinal
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why is spinal anesth preferred method of anesthesia for TURP pts?
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-decreased blood loss
-decreased thrombus risk -atonic bladder w/ lg capacity -prevents post-op bladder spasm -awake pt helps w/ early detection of complications |
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what level is required for spinal for TURP?
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T10
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what are complications of TURP?
|
-blood loss
-increased intravascular volume and dilutional hyponatremia |
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what is usual loss during TURP?
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10-30ml/min
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what is absorption dependent upon in TURP?
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ht of container
time of resection |
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what are triad of symptoms of TURP syndrome in awake pt?
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1-increased pulse pressure
2-decreased HR 3-mental status changes |
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what are other s/s of TURP syndrome?
|
-HTN
-bradycardia -angina -CV collapse -dyspnea -nausea -apprehension, disorientation,, seizures, coma |
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what is managment of TURP syndrome?
|
-ask surgeon to control bldg and terminate resection
-send lytes to lab -fluid restriction -lasix 10-20mg -hypertonic saline |
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when is low Na+ level serious?
|
<120
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how do you figure dose of hypertonic saline?
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weight (kg) x (140-serum Na+ level)
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what should rate of hypertonic saline not exceed?
|
100ml/hr
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what may result from too rapid infusion of hypertonic saline?
|
central pontine myelinolysis
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what meds should be used if pt has seizure?
|
-midazolam
-thiopental -diazepam -phenytoin |
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what are s/s of perforation w/ extravastion of irrigation fluid?
|
-suprapubic fullness
-abd spasm and pain -HTN and tachycardia followed by sudden and severe hypotension - |
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what is intraperitoneal perforation signalled by?
|
-abd pain
-shoulder pain -distension -CV collapse |
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what does methylene blue cause?
|
causes hypotension
|
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what does indigo carmine use?
|
sympathomimetic, increase BP
|
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what are complications of open prostate proc?
|
-hypothermia
-anemia -coagulopathy |
|
|
what involves removal of bladder and creating conduit for urine from portion of bowle?
|
radical cystectomy and ileal/colonic conduit
|
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what are complications of ileal/colonic conduit?
|
-hypothermia
-volume -post-op vent failure d/t fluid shifts length of surgery |
|
|
what is ESWl?
|
extracorporeal shock wave lithotripsy
|
|
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what level of block is required for ESWL?
|
T4-6
|
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what is managment of pt for ESWL?
|
-reduce delivered TV
-aim for HR of 70-115bpm -IV hydration and diuretics -protect pt and staff ears -xray lead apron |
|
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what are complications of ESWL?
|
ureteral colic
hematuria |
