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194 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
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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%
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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
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-pneumothorax
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pneumomediastinum
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subq emphysema is from what?
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extraperitoneal insufflation
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how does pneumothroax etc occur with gas insufflation?
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-via defects in diaphgram
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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
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auscultate 100% o2 No N20 Peep decrease abdominal pressure
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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 pressures
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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
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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
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what occurs with a gas lock in vena cava and right atrium?
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-obstructs venous return
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how is gas embolism diagnosed?
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-change in doppler
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-at 2ml/kg see tachy
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dsyrhythmias
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what is treatment of gas embolism?
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-stop insufflation
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-left side down
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head down
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what are some possible causes for increased N/V risk in laprascopic surgeries?
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-young
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what should plan for antiemetic?
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-ondansetron
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if pt has history N/V what should you do?
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-avoid inhalation agents/nitrous oxide
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what is anesthetic managment for laprascopic abd surgeries?
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-GA required
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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
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what are cons of colloids?
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-expense
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what are cystalloid pros?
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-cheap
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what are crystalloid cons?
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-don't stay in intravascular space very long T1/2=20-30min
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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
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what are s/s of hypovolemia/fluid assessment?
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-tachycardia
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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
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choice of anesthetic is dependent upon what?
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-duration
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what types of cases or pt need RSI?
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-trauma or other emergent cases
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-ascites
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diabetics and renal pts
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what may be some pretreatments for RSI?
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-bicitra
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what is sequence of RSI?
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-pretreatment
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what does bicitra do?
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-decrease acidity in gut
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what does ranitidine do?
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decrease amt of acid
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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
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what are s/s of mendelson syndrome?
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-hypoxia
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-ABG alterations (decrease PaO2
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increase PaCO2
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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
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how do you reduce risk of mendelson syndrome?
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-accelerate gastric emptying
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what is tx of acid aspiration?
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-head down
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-bronchoscopy
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pulm lavage
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when should you avoid nitrous?
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-on trauma pts
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what can you do to help with pulmonary comprise when surgeon is using retractors?
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-add PEEP'
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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
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what are effects of hypothermia w/ anesthesia?
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-decreased BMR
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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
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how can you prevent heat loss?
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-warming blankets
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how can you tx hiccups?
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-muscle relaxants
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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
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because of increased O2 consumption what happens?
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-increased metabolic activity of fat
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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
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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
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what happens to cardiac system in obese pts?
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-increased blood volume
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-increased pulm blood volume
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increased pulm HTN
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what happens to endocrine system in obese pts?
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-impaired glucose tolerance
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what happens to GI system in obese pts?
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-hiatal hernia
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why are obese pts difficult airways?
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-neck flexion limited by "chins" and chest wall fat
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what is distribution affected by?
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-increased CO
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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
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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
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what makes Regional Anes
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. difficult on obese pts?
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what are obese pts at risk for post-op?
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-hypoxemia
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what are some other concerns w/ open choles?
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-increased cost
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what are the five F's of cholellithiasis?
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-female
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how can you tx shincter of oddi spasm?
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-NTG
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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
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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
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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
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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
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but greater than ____?
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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
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what muscle relaxants shoud be avoided?
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-succs
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what are useful anesthetic drugs in pts with pheo?
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-inhalation agents
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-esmolol
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regisitine
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what are some other medications that should be avoided in pts w/ pheo?
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-avoid histamine releasers
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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
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what does histamine release cause?
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-vasodilation
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what does serotonin cause?
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-vasoconstriction
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what do kallikreins cause?
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vasodilation
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what do bradykinins cause?
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hypotension
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(minor effects compared to histamine
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serotonin
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what are s/s of carcinoid syndrome?
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-bronchoconstriction
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-tricuspic regur
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pulmonic stenosis
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how is diagnosis of carcinoid syndrome made?
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via metabolite in urine
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what is anesthetic managment of carcinoid syndrome?
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-octreotide
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what are some other anesthetic considerations in pts w/ carcinoid syndrome?
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-avoid hypotension
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what are CV changes in the elderly?
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-decrease arterial elasticity
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-increased afterload
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SBP
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what are pulm changes in elderly?
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-decreased elasticity
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what are CNS changes in elderly?
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-cerebral blood flow and brain mass decrease
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what are renal changes in elderly?
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-renal blood flow and mass decrease
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what are hepatic changes?
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-decreased hepatic blood flow and mass
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why is pharmacology compromised in elderly?
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-decreased hepatic and renal functions
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-decreased muscle mass
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blood volume
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what are anesthetic considerations in the elderly?
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-decrease narcs by 50%
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what kind of anes is used for cysto?
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-MAC
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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
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what is peritoneal invasion in awake patient signaled by?
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-shoulder pain
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if there is peritoneal invasion what are s/s see in pt under GA?
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-unexplained HTN
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what can infusion of glycine cause?
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-hyperglycinemia
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what are s/s of hyperglycinemia?
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-circulatory depression/hypotension
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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
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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?
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-blood loss
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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
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what are triad of symptoms of TURP syndrome in awake pt?
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1-increased pulse pressure
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what are other s/s of TURP syndrome?
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-HTN
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-apprehension
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disorientation
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what is managment of TURP syndrome?
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-ask surgeon to control bleeding and terminate resection
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when is low serum Na+ level serious?
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<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?
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100ml/hr
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what may result from too rapid infusion of hypertonic saline?
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central pontine myelinolysis
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what meds should be used if pt has seizure?
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-midazolam
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what are s/s of perforation w/ extravastion of irrigation fluid?
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-suprapubic fullness
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what is intraperitoneal perforation signalled by?
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-abd pain
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what does methylene blue cause?
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causes hypotension
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what does indigo carmine use?
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sympathomimetic
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what are complications of open prostate proc?
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-hypothermia
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what involves removal of bladder and creating conduit for urine from portion of bowle?
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radical cystectomy and ileal/colonic conduit
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what are complications of ileal/colonic conduit?
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-hypothermia
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what is ESWl?
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extracorporeal shock wave lithotripsy
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what level of block is required for ESWL?
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T4-6
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what is managment of pt for ESWL?
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-reduce delivered TV
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what are complications of ESWL?
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ureteral colic
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Pt population of amputations
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trauma, diabetics, PVD, CAD, pulmonary disease, and smoker
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Epidurals and amputations
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reduce phantom limb pain postop
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Our goal for reimplantations
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maximize perfusion
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Anesthesia interventions for reimplantation procedure
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maintain temp, positioning, passive ROM, Hydration, humidify airway
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Is regional anesthesia used for reimplantation?
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Isolated areas only, increase peripheral blood flow by interrupting sympathetic innervation
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How to avoid hypothermia
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Bair hugger, warm fluids, warm OR, avoid vasoconstrictors
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Pulmonary effects of scoliosis
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decrease lung volume, increased work of breathing, alveolar hypoventilation, poor cough, restrictive airway disease, pulmonary hypertension, VQ mismatch, increased A-A gradient, increased risk for post op ventilatory failure.
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What does the wake up test, test
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anterior cord function
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What do SSEPs test
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Posterior cord function
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