Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
204 Cards in this Set
- Front
- Back
|
What is at risk during trocar insertion?
|
Major organ or vessel entry that could lead to hemorrhage or peritonitis
|
|
|
What are some hemodynamic changes that occur with gas insufflation during laparoscopic surgery?
|
Increased intra-abdominal pressure, impaired venous return & increased SVR
|
|
|
What are some pulmonary changes that occur with gas insufflation during laparoscopic surgery?
|
Pressure on diaphragm interferes with normal ventilation & oxygenation decreasing pulmonary compliance & FRC, causing VQ mismatch, hypercapnia & impaired ventilation
|
|
|
By what percentage is pulmonary compliance decreased with gas insufflation?
|
30-50%
|
|
|
What are some complications of gas insufflation during laparoscopic surgery?
|
Subcutaneous emphysema, pneumothorax, pneumomediastinum, pneumopericardium, endobronchial intubation and CO2 gas embolism
|
|
|
T/F Patients undergoing laparoscopic surgery is at risk for increased aspiration risk
|
True
|
|
|
What are some factors that can lead to pneumothorax, pneumomediastinum or pneumopericardium during laparoscopic surgery?
|
Defects in diaphragm, aorta or esophagus
Pleural tears Bullae rupture |
|
|
What are some s/sx seen if pneumothorax, pneumomediastinum & pneumopericardium?
|
Decreased airway compliance, increased airway pressure, gas absorption leading to increased ETCO2 & can result in tension pneumothorax
|
|
|
With bullae rupture during laparoscopic surgery, what will happen to ETCO2?
|
It will decrease
|
|
|
What is the treatment for pneumothorax?
|
Auscultate breath sounds to confirm, 100% oxygen, adjust ventilation to correct hypoxemia & hypercapnia, add PEEP (except with bullae rupture) & decrease intra-abdominal pressure
|
|
|
Why does endobronchial intubation sometimes occur following insufflation?
|
Carina can move cephalad, leading to right mainstem intubation
|
|
|
What causes a CO2 gas embolism?
|
Direct injection into vessel via trocar or needle or insufflation of gas into abdominal wall & peritoneal vessels
|
|
|
Why is CO2 used for gas insufflation?
|
More soluble in blood than oxygen, air or nitrous oxide & rapid elimination increases margin of safety
|
|
|
Why is CO2 so soluble in blood?
|
Bicarbonate buffering & combination with hemoglobin & plasma proteins
|
|
|
What is the recommended rate of gas insufflation?
|
< 1 L/min
|
|
|
What occurs with gas (CO2) lock in vena cava & right atrium?
|
Obstructs venous return, decreases CO & increased dead space ventilation & hypoxemia
|
|
|
What occurs when a patient has a PFO & a CO2 gas embolism is injected during laparoscopic surgery?
|
Paradoxical gas embolism
|
|
|
What are some diagnostic signs of CO2 gas embolism?
|
Change in doppler sound (mill wheel murmur), increased PAP, increased CVP, profound hypotension, tachycardia, dysrhythmias, pulmonary edema, decreased ETCO2, decreased CO & increased dead space
|
|
|
What is treatment for a CO2 gas embolism?
|
Release pneumoperitoneum, left side & head down, 100% oxygen, aspirate gas or foamy blood from CVP & CPR or bypass if unable to remove embolism
|
|
|
What is the cause of increased nausea & vomiting with laparoscopic procedures?
|
True cause unknown; suspected factors include: young, female & gas pressure on gut
|
|
|
What are some ways to prevent PONV following laparoscopic procedures?
|
IV hydration, antiemetics & OG to empty stomach
|
|
|
What are some reasons that patient's undergoing abdominal procedures are dehydrated prior to surgery?
|
GI bleed, diarrhea, fever, fluid sequestration in bowel, emesis, gastric drainage (OG/NG) & bowel prep
|
|
|
What are some s/sx of hypovolemia?
|
Tachycardia, orthostatic changes, hypotension, dry mouth, decreased skin turgor, respiratory variation on ECG, hematocrit & BUN elevated & cool, mottled skin
|
|
|
When does mobilization of surgical fluid occur?
|
Postop day 3
|
|
|
What metabolic derangements occur with large GI losses?
|
Hypokalemia & metabolic alkalosis
|
|
|
What metabolic derangement occurs with diarrhea or septicemia?
|
Metabolic acidosis
|
|
|
Describe a fluid plan for a patient.
|
Maintenance: wt(kg) + 40 = mL/hr
Deficit: Maintenance x NPO (hrs) = mL (replace over 3 hours, 1/2 of volume in first hour, 1/4 of volume in second & third hour) Third Space Loss: Min 2-4 mL/kg/hr Mod 4-6 mL/kg/hr Major 6-10 mL/kg/hr |
|
|
What are some general components of the anesthesia plan for a patient undergoing laparoscopic abdominal surgery?
|
General anesthesia with ETT, nitrous oxide okay if procedure is elective & deep anesthesia or muscle relaxation
|
|
|
What type of anesthesia may be used for very large open abdominal procedure?
|
Epidural with general anesthesia, reduces anesthetic requirements & good for postop pain management
|
|
|
What are some indications for RSI for abdominal surgery?
|
Emergent cases, trauma, bowel obstruction, hiatal hernia, obesity, ascites, diabetes, renal patients & pregnancy
|
|
|
What is Mendelson syndrome? What does it result in?
|
Acid aspiration syndrome
Atelectasis, alveolar edema, loss of surfactant & small airway obstruction |
|
|
What causes an increased risk of Mendelson syndrome?
|
Volume of aspirate > 25 mL & pH of aspirate < 2.5
|
|
|
What are s/sx of Mendelson syndrome?
|
Hypoxia, wheezing, tachycardia, tachypnea, hypotension & ABG alterations: decreased PaO2, increased PaCO2 & acidosis
|
|
|
How can the risk of Mendelson syndrome be reduced?
|
Accelerate gastric emptying (metoclopramide), increase gastric pH (H2 receptor antagonists-famotidine or antacids-bicitra), increase lower esophageal sphincter tone (metoclopramide) &/or empty stomach
|
|
|
What are treatments for Mendelson syndrome?
|
Head down during intubation, suction mouth & trachea, positive pressure ventilation c/ PEEP, bronchoscopy c/ pulmonary lavage, antibiotics & steroids
|
|
|
What can abdominal surgical retractors do to ventilation? What is the treatment?
|
Cause elevation of diaphragm leading to decreased FRC.
Add PEEP, increase TV or put in a PC mode |
|
|
Bowel manipulation can cause what hemodynamic effect?
|
Hypotension
|
|
|
Treatments for hiccoughs?
|
Deepen anesthesia, muscle relaxants, remove source of irritation (surgical retractors) or chlorpromazine 5 mg
|
|
|
What are the mechanisms of heat loss?
|
Radiation, conduction, convection & evaporation
|
|
|
What factors during anesthesia/surgery in increase heat loss?
|
Low OR room temperatures, room temperature IV or irrigation fluids, dry anesthetic gases & exposure of body surfaces & viscera
|
|
|
What are the effects of hypothermia under anesthesia?
|
Decreased BMR, peripheral vasoconstriction, leftward shift of oxyhemoglobin dissociation curve (decreased oxygen unloading at tissues), ineffective blood coagulation, ineffective muscle relaxant reversal, poor wound healing & vfib occurs at temperatures < 94 degrees F
|
|
|
How is heat loss prevented during anesthesia?
|
Warm blankets, Bair hugger, plastic wrap, warm OR room temperature, warm fluids, low gas flow & airway humidifying filters
|
|
|
What are the five "F's" that are at increased risk for gallbladder problems?
|
Fat, forty, female, fertile & fair
|
|
|
What is the gallbladder position?
|
Reverse trendelenberg with right side up
|
|
|
What can narcotics cause that would interfere with the results of a cholangiogram? What is the treatment?
|
Spasm of sphincter of Oddi
NTG, glucagon or narcan |
|
|
What does a BMI > 28 represent? > 35?
|
20% above ideal body weight
Morbid obesity |
|
|
What type of obesity is at higher risk for CV disease & increased oxygen consumption?
|
Truncal
|
|
|
Why does increased oxygen consumption occur with obesity?
|
Increased metabolic activity of fat, increased locomotive activity & increased work of breathing
|
|
|
What occurs in obesity due to increased metabolic activity & oxygen consumption?
|
Increased carbon dioxide production
|
|
|
How do lung volumes change with obesity?
|
Decreased FRC, VC & ERV; TV falls within closing capacity (falls further when in supine position)
|
|
|
What occurs to PFTs with obesity?
|
Usually normal, does not mean they are not hypoxic at baseline
|
|
|
To what degree does anesthesia reduce FRC in the obese patient? The non-obese patient?
|
50%
20% |
|
|
What type of respiratory changes occur with obesity?
|
VQ mismatch, hypoxemia, right to left shunt, limited ventilatory capacity & increased respiratory rate
|
|
|
Do obese patients usually demonstrate restrictive or obstructive lung disease? Why?
|
Restrictive due to poor chest wall compliance & increased pulmonary blood volume
|
|
|
What is obesity hypoventilation syndrome? How is this manifested?
|
Loss of hypercarbic drive, depend on hypoxic drive for ventilation
Sleep apnea, hypersomnolence & airway difficulties |
|
|
What is Pickwickian syndrome? What is seen with these patients?
|
Extreme obesity hypoventilation syndrome
Increased ETCO2 at baseline, hypoxemia (PaO2 < 60 mmHg), polycythemia, pulmonary HTN & biventricular failure |
|
|
What are some CV changes that occur with obesity?
|
Increased blood volume & CO, splanchnic blood flow increases 20%, HTN, increased ECF volume, cardiomegaly, ischemic heart disease, CHF & limited cardiac reserve (impaired systolic & diastolic fxn, EF normal at rest but cannot increase c/ exercise)
|
|
|
What are some renal changes that occur with obesity?
|
Increased GFR, impaired natriuesis leading to activation of SNS & RAAS & physical compression of the kidney
|
|
|
What are endocrine/metabolic changes that occur with obesity?
|
Impaired glucose tolerance: resistance of peripheral fatty tissues to insulin & islet cell hypertrophy. Abnormal lipids leading to increased risk of gallbladder & biliary disease.
|
|
|
What are some GI changes that occur with obesity?
|
Higher incidence of hiatal hernias & GERD (increased intra-abdominal pressure), increase volume & acidity of stomach contents (even following fasting may have volume > 25 mL) & increased liver fat (hepatic clearance usually not affected)
|
|
|
What are some airway changes that occur with obesity?
|
Limited neck flexion (chin/chest wall fat, thoracic/cervical fat pads), redundant soft tissue in mouth & pharynx, large tongue & sleep apnea
|
|
|
What are some alterations in volume of distribution for medications that occur with obesity?
|
Decreased total body water, increased total body fat, increased lean body mass, increased blood volume & altered protein binding
|
|
|
Will water soluble or fat soluble medications have a larger volume of distribution with obesity? Smaller volume of distribution?
|
Fat soluble
Water soluble |
|
|
Which drugs will have a longer half-life, normal clearance & may require higher initial dose due to larger volume of distribution?
|
Fat soluble drugs like benzodiazepines & thiopental
|
|
|
What are changes in the pharmacokinetics of propofol with obesity?
|
Increased volume of distribution & clearance, recovery unchanged
|
|
|
Why should all opioids be used with caution in an obese patient?
|
Patients may have increased sensitivity to all CNS depressants & potential for upper airway obstruction
|
|
|
How do the pharmacokinetics of alfentanil change when using with an obese patient? Sufentanil?
|
Longer half-life due to reduced clearance
Longer half-life due to increased volume of distribution (highly lipophilic) |
|
|
Why does the dose of succinylcholine change when used with an obese patient? What dose should be given?
|
Obese patients have increased pseudocholinesterase activity, succinylcholine dose should be increased to 1.2-1.5 mg/kg
|
|
|
What muscle relaxants should be dosed per actual body weight, no matter the weight?
|
Atracurium & cisatracurium
|
|
|
What muscle relaxants should be dosed at lean body mass?
|
Vecuronium & rocuronium
|
|
|
What muscle relaxant should be dosed above lean body mass for obese patients?
|
Pancuronium
|
|
|
Increased alpha-1 acid glycoprotein & triglycerides in obesity affect what? What results?
|
Plasma protein binding; resulting in decreased free drug concentration, increased GFR & tubular secretion & increased renal clearance
|
|
|
What changes occur in phase I reactions with obesity? What are these reactions?
|
No change
Oxidation, reduction & hydrolysis |
|
|
What changes occur in phase II reactions with obesity?
|
Glucuronidation & sulfation cleared faster
Acetylation is unchanged |
|
|
When is an awake intubation recommended with obese patients?
|
When > 75% above ideal body weight
|
|
|
If an obese patient has pickwickian syndrome, who should be consulted?
|
Cardiology
|
|
|
What is contraindicated for anesthesia management for obese patients?
|
LMA
|
|
|
In what situations is it okay to premedicate obese patients?
|
Only if monitoring
|
|
|
What is key to positioning an obese patient for intubation?
|
Chin higher than the chest
|
|
|
What are important things to consider if doing a RSI c/ an obese patient?
|
Increase succinylcholine dose (increased pseudocholinesterase activity) & ensure adequate preoxygenation (rapid desaturation will occur secondary to increased oxygen consumption & decreased FRC)
|
|
|
Is nitrous oxide a good choice with obese patients? Why or why not?
|
Yes; not fat soluble & rapidly eliminated, however, may not be an option if > 50% oxygen needed to maintain oxygen saturation
|
|
|
T/F Metabolism of inhalation agents is decreased with obesity
|
False, it is increased
|
|
|
Why is careful positioning important with obese patients?
|
Pressure sores & neural injuries are common
|
|
|
In what conditions should you extubate an obese patient?
|
Awake & sitting
|
|
|
Should epidural & spinal doses of local anesthetics be increased or decreased for obese patients? Why?
|
Decreased by 25%, these patients have epidural vascular engorgement & fatty infiltration that reduces volume of epidural space
|
|
|
Might it be more technically difficult to place a spinal or epidural with an obese patient? Why or why not?
|
Yes, longer needles needed to reach spine & landmarks are poor
|
|
|
What are some postoperative considerations for obese patients?
|
Increased respiratory complications (atelectasis, hypoxemia, CPAP/BiPAP need), DVT & use caution with opioid administration (sleep apnea & CNS depressants)
|
|
|
What is a pheochromocytoma?
|
Catecholamine secreting tumor arising from the chromaffin tissue of the adrenal medulla 95% of the time
|
|
|
Besides the adrenal medulla, where can pheochromocytomas found?
|
Right atrium, spleen, ovary, aorta & lymphatic spread to the liver
|
|
|
What catecholamines are secreted by pheochromocytoma? What are their effects?
|
Norepinephrine > epinephrine
Alpha-1 stimulation: increased PVR & SVR, decreased intravascular volume (increased Hct), renal failure, cerebral hemorrhage, increased myocardial work & increased glucose |
|
|
What is the most sensitive indicator used for diagnosis of pheochromocytoma?
|
24 hr urine collection with norepinephrine & epinephrine
|
|
|
What is the triad of sx associated c/ pheochromocytoma?
|
HTN associated with: diaphoresis, tachycardia & HA
|
|
|
What is definitive treatment of pheochromocytoma? What can occur with treatment?
|
Tumor removal
Removal of adrenal tissue, cortisol must be given to these patients |
|
|
With pheochromocytoma, alpha & beta antagonist therapy is administered preoperatively, what must be blocked first? Why?
|
Alpha, beta blockade without alpha blockade would lead to unopposed alpha stimulation (intense vasoconstriction)
|
|
|
What are the alpha antagonists given for pheochromocytoma? What time period should they be administered for?
|
Phenoxybenzamine: administer for 10-14 days prior to surgery
Phentolamine Both nonselective alpha antagonists |
|
|
What are the beta blockers used with pheochromocytoma?
|
Atenolol & esmolol
|
|
|
What can occur with manipulation of pheochromocytoma? What is a drug to counteract this problem?
|
Catecholamines are released
Nitroprusside |
|
|
What medication can be give after pheochromocytoma removal in the event of hypotension?
|
Phenylephrine
|
|
|
What can be given to treat arrhythmias seen during pheochromocytoma removal?
|
Lidocaine
|
|
|
What medications are avoided during pheochromocytoma surgery?
|
Sympathomimetics, ketamine, droperidol, succinylcholine, pancuronium & histamine releasing agents
|
|
|
What does droperidol cause that can affect the patient with pheochromocytoma?
|
Antagonizes presynaptic dopaminergic receptors that normally inhibit catecholamine release
|
|
|
What are some considerations prior to pheochromocytoma removal?
|
Alpha & beta blockade, adequate hydration prior to induction, arterial line & consider PA catheter to monitor volume status
|
|
|
What two things dose succinylcholine cause that can affect the patient with pheochromocytoma?
|
Histamine release & fasciculations may stimulate catecholamine release
|
|
|
What does pancuronium cause that can affect the patient with pheochromocytoma?
|
Vagolytic, cardiac effects & HTN
|
|
|
What are carcinoid tumors?
|
Tumors derived from enterochromaffin cells generally found in the GI tract (75%)
|
|
|
What are locations of carcinoid tumors other than the GI tract?
|
Lungs, liver & ovaries
|
|
|
What happens with most secretions from carcinoid tumors?
|
Delivered to liver & inactivated via first pass elimination
|
|
|
What is carcinoid syndrome?
|
Results from vasoactive substance released from carcinoid tumor; including histamine, serotonin, kallikreins & bradykinins
|
|
|
What does histamine cause in carcinoid syndrome?
|
Vasodilation, bronchoconstriction & dysrhythmias
|
|
|
What does serotonin cause in carcinoid syndrome?
|
Vasoconstriction, increased intestinal tone, electrolyte imbalance & inotropic & chronotropic effects
|
|
|
What do kallikreins cause in carcinoid syndrome?
|
Vasodilation & bronchoconstriction
|
|
|
What do bradykinins cause in carcinoid syndrome?
|
Minor effects, bronchoconstriction & vasodilation
|
|
|
What are sx of carcinoid syndrome?
|
Bronchoconstriction, right side heart effects (tricuspid regurgitation, pulmonic stenosis), dysrhythmias, flushing, diarrhea, abdominal pain, hepatomegaly, hyperglycemia, decreased albumin & labile vital signs
|
|
|
How is carcinoid syndrome diagnosed?
|
5-HIAA, a serontonin metabolite in the urine
|
|
|
What is the goal during surgery for carcinoid syndrome? What are some medications used?
|
Goal is to block or antagonize the effects of vasoactive substances
Somatostatin (reduces serotonin release), octreotide (synthetic somatostatin analogue), corticosteroids (inhibit bradykinin) & antihistamines (H2 blockers & benadryl) |
|
|
Why is it important to avoid hypotension during carcinoid tumor removal? One way to avoid hypotension?
|
Increases release of hormones from tumor
IV hydration |
|
|
What medications should be avoided with carcinoid tumors?
|
Histamine releasing medications
|
|
|
Why is zofran a good medication for carcinoid tumors?
|
Serotonin antagonist
|
|
|
T/F SNS stimulation should be avoided during carcinoid tumor removal
|
True
|
|
|
What age group do patients undergoing genitourological procedures tend to be?
|
Elderly
|
|
|
What are some CV changes seen in elderly patients?
|
Myocardial fibrosis decreases myocardial contractility, decreased arterial elasticity increases afterload (HTN & LVH), decreased baroreceptor activity, increased vagal tone, decreased sensitivity of adrenergic receptors & dysrhythmias
|
|
|
What are some pulmonary changes seen in elderly patients?
|
Decreased lung elasticity (overdistension of alveoli & small airway collapse) increases dead space, reduced alveolar surface area & efficiency of gas exchange, increased RV & closing capacity, increased chest wall rigidity, decreased muscle strength & blunted response to hypercapnia & hypoxia
|
|
|
What are some CNS changes seen in elderly patients?
|
Decreased cerebral blood flow & brain mass, cerebral autoregulation is preserved, perceptive changes (slowed conduction in peripheral nerves) & cognitive defects (loss of neurons)
|
|
|
What are some renal changes seen in elderly patients?
|
Decreased renal blood flow & renal mass, decreased creatinine clearance & GFR, impaired sodium handling (concentrating ability & diluting capacity) & increased risk of acute renal failure
|
|
|
What are some hepatic changes seen in elderly patients?
|
Decreased hepatic blood flow & mass, decreased biotransformation rate & albumin production & decreased plasma cholinesterase levels in men
|
|
|
What are changes in pharmacokinetics that occur in the elderly?
|
Decreased hepatic & renal functions, changes in protein binding & decreased muscle mass, blood volume & lean body mass
|
|
|
What are anesthetic considerations with elderly patients?
|
Patients often have multiple co-morbidities, reduced medication requirements (increased risk of postoperative cognitive dysfunction), care with moving & positioning & increased risk of hypothermia
|
|
|
What spinal block level is necessary for cystoscopy?
|
T10
|
|
|
What spinal block level is necessary for cystoscopy with retrogrades?
|
T6
|
|
|
What does cystoscopy with retrogrades include?
|
Instrumentation of ureters (more painful)
|
|
|
What type of anesthetic is preferred for transurethral resection of the bladder? Why?
|
General anesthesia, b/c regional anesthesia increases risk of bladder perforation
|
|
|
What are complications of transurethral resection of the bladder?
|
Blood loss, hypothermia, bacteremia & bladder perforation
|
|
|
What are s/sx of peritoneal invasion in an awake patient?
|
Sudden, severe abdominal pain, shoulder pain, n/v & abdominal rigidity
|
|
|
What are s/sx of peritoneal invasion in a patient under general anesthesia?
|
Unexplained HTN & tachycardia
|
|
|
What can occur with bladder perforation if patient has a high grade malignancy?
|
Increased risk of seeding
|
|
|
Why is irrigating fluid used in TURP procedures?
|
Causes bladder distention allowing visibility & removal of dissected tissue & blood
|
|
|
What are some characteristics of irrigating fluid used for TURP?
|
Hypotonic & non-electrolyte solutions that can cause toxicity
|
|
|
What are two things glycine can cause when used as an irrigating fluid for a TURP?
|
Hyperglycinemia: Circulatory depression, CNS toxicity & transient blindness (inhibition of optic nerve)
Hyperammonemia: Glycine metabolized to ammonia by liver, levels can exceed 500 micromoles/L (normal 5-50 micromoles/L) |
|
|
If sorbitol & dextrose are used as an irrigating fluid for a TURP what are some side effects?
|
Hyperglycemia & osmotic diuresis
|
|
|
What can occur with mannitol use as the irrigating fluid for a TURP?
|
Intravascular volume expansion & osmotic diuresis
|
|
|
What type of anesthetic preferred for TURP procedure? Why?
|
Regional anesthesia; decreased blood loss, decreased thrombus risk, atonic bladder, prevents postoperative bladder spasm & an awake patient assists in early detection of complications
|
|
|
What level of spinal block is required for a TURP?
|
T10
|
|
|
What are complications of TURP?
|
Blood loss, venous absorption of irrigating fluid, TURP syndrome, bladder perforation, bacteremia, hypothermia & coagulopathy
|
|
|
Why is blood loss difficult to estimate with a TURP?
|
Irrigation
|
|
|
Why does venous absorption of irrigation fluid occur with TURP? What is the result of this?
|
Venous sinuses in prostate
Increase intravascular volume & dilutional hyponatremia |
|
|
What does the absorption of irrigating fluid during a TURP depend on?
|
Number & size of venous sinuses open, height of irrigating fluid & time (length) of resection
|
|
|
What are the TURP syndrome triad of symptoms? What are other symptoms?
|
Increased pulse pressure, bradycardia & mental status changes
HTN, CV collapse, increased CVP, dyspnea, nausea, anxiety, disorientation, seizures & coma |
|
|
What is included in the management of TURP syndrome?
|
Stop the resection, fluid restriction, lasix & hypertonic saline (3% saline)
|
|
|
What lab indicate TURP syndrome? When are seizures, loss of consciousness seen?
|
Sodium < 120
Sodium < 110 |
|
|
How should hypertonic saline be dosed? What is the maximum rate that can be administered? When should it be stopped?
|
Dose (mEq) = Wt (kg) x (140-Current sodium level)
100 mL/hr When sodium > 120 |
|
|
What can result from rapid infusion of hypertonic saline correcting sodium level too quickly?
|
Central pontine myelinolysis: permanent destruction of the myelin sheath
|
|
|
What can occur with bladder perforation during TURP? What are s/sx of this?
|
Extravasation of irrigating fluid into extraperitoneal cavity
Abdominal spasm & pain, suprapubic fullness, HTN & tachycardia followed by sudden & severe hypotension |
|
|
Why does coagulopathy occur with TURP? What can result?
|
Prostate tissue contains thromboplastins
DIC & dilutional thrombocytopenia |
|
|
What are patients undergoing open prostatectomy at risk for? How should you prepare for this?
|
Large blood loss
T&C, 2 large bore IVs |
|
|
Why is dye used in open prostatectomy? What dyes are used? What can be a side effect?
|
Assess for patency of urinary drainage system
Methylene blue & indigo carmine Transient artificial decrease in oxygen saturation |
|
|
Are open prostatectomies usually done with a general anesthetic or regional?
|
Length of procedure usually leads to a general anesthetic
|
|
|
What are complications of an open prostatectomy?
|
Hypothermia, anemia & coagulopathy
|
|
|
What is normally done prior to radical cystectomy?
|
Bowel preparation, patient will be dehydrated
|
|
|
Why will urine output be difficult to assess during radical cystectomy?
|
Open bladder
|
|
|
What are complications of radical cystectomy?
|
Large blood loss, hypothermia (lengthy procedure) & at risk for postoperative ventilatory failure (fluid shifts & long procedure)
|
|
|
What is extracorporeal shock wave lithotripsy (ESWL)?
|
Treatment of stones in upper ureter or kidney by using repetitive hi-energy shocks (sound waves) to break up
|
|
|
What do the shocks during ESWL trigger off of? Why?
|
ECG R-wave (ventricular refractory period)
Prevents arrhythmias |
|
|
What level spinal block is used for ESWL?
|
T4-6
|
|
|
Why is general anesthesia effective for ESWL?
|
Controlled ventilation minimizes risk of lung trauma
|
|
|
What are some anesthetic considerations for ESWL?
|
Hearing protection (staff & patient), fluoroscopy being used, IV hydration & diuretics & reduce delivered TV
|
|
|
What are complications of ESWL?
|
Ureteral colic (painful, requires stents) & hematuria (damage to urinary system)
|
|
|
What are contraindications for organ donation?
|
Absolute: extracranial malignancy & untreatable infections
Relative: Drug abuse, noncompliance & age |
|
|
What percentage of deaths meet the criteria for cadaveric organ donation? What percentage of those eligible actually become donors?
|
5%
10-20% (medical failure, unable to obtain consent, cultural differences) |
|
|
What are brain death criteria?
|
Comatose, no spontaneous mvmt, no response to painful stimuli, exclusion of reversible causes of cerebral dysfunction (hypothermia, drug effects), lack of brainstem reflexes & apnea test
|
|
|
What brainstem reflexes shouldn't be present to meet brain death criteria?
|
Pupillary response to light, corneal reflex, oculocephalic reflex, oculovestibular reflex, gag/cough reflex & facial motor response
|
|
|
Describe the apnea test?
|
100% oxygen for 10 min, confirm PaCO2 normal, disconnect from ventilator, oxygen via t-piece for 7-10 minutes, patient meets brain death criteria if PaCO2 > 60 mmHg on repeat ABGs
|
|
|
Describe harvesting.
|
Surgeons isolate organs with preservation of their central vascular structures & remove by order of susceptibility to ischemia (heart first, kidneys last), under cold protection (ice). Give heparin & cross-clamp aorta immediately prior to removal.
|
|
|
Why is hypotension present during organ harvesting?
|
Decreased CO, decreased SVR & myocardial dysfunction
|
|
|
Why is poor oxygenation present during organ harvesting?
|
Neurogenic pulmonary edema & diabetes insipidus
|
|
|
T/F Neuromuscular blockade makes no difference during organ harvesting
|
False, facilitates surgical access
|
|
|
Is atropine an effective medication for bradycardia during organ harvesting?
|
No, isoproterenol (parasympatholytic) is preferred
|
|
|
What are some concerns during organ harvesting?
|
Hyperglycemia, coagulopathy & hypothermia
|
|
|
Should analgesia be administered during organ harvesting?
|
No perception of pain, may be given to maintain hemodynamic stability
|
|
|
When is donation after cardiac death an option?
|
When patient expected to go into cardiac arrest within 30 minutes after ceasing all medical care
|
|
|
What kidney is typically taken from a living organ donor? Why?
|
Left, better surgical exposure & longer vascular supply
|
|
|
What is the maintenance rate for a kidney donor during surgery?
|
10-20 mL/kg/hr
|
|
|
Why may lasix or mannitol be given to a kidney donor?
|
To facilitate diuresis
|
|
|
Where is incision made with an open procedure for kidney donation?
|
Subcostal lateral
|
|
|
What position is the patient in for kidney donation?
|
Lateral, table flexed c/ kidney rest elevated
|
|
|
What is given prior to clamping before kidney removal during donation?
|
Heparin
|
|
|
What type of co-morbidities are common with patients receiving a kidney (ESRD)?
|
Cardiomyopathy, LVH, CHF, HTN, atherosclerosis, diabetes, diabetic neuropathy, delayed gastric emptying, anemia & coagulopathies
|
|
|
What is important to assess preoperatively for patient receiving a kidney?
|
Last dialysis (K < 6), echo, beta blocker use (start if not on), glucose level, INR, plts, corticosteroids & anti-rejection medication
|
|
|
What types of NMB should be used for kidney recipient?
|
Nimbex, rocuronium or vecuronium (new kidney will be able to excrete drug)
|
|
|
What should be used to avoid hypotension during kidney transplant?
|
IV fluid & vasopressors
|
|
|
Why is mannitol used during surgery for kidney recipient?
|
Osmotic diuresis & ischemic injury protection
|
|
|
T/F Liver can recover function in both donor & recipient
|
True, can take weeks to months
|
|
|
What part of the liver is usually transplanted?
|
Right hepatic lobe (500-1000 g), leaves donor c/ 1/3 of original liver mass
|
|
|
What are some relative contraindications to receiving a liver transplant?
|
Significant CAD, pulmonary HTN & compliance
|
|
|
What causes end-stage liver disease?
|
Hep C, ETOH, biliary cirrhosis, metabolic disease (Wilson's disease), hepatocellular disease & drug induced
|
|
|
What are some systemic manifestations of end-stage liver disease?
|
Portal HTN, ascites, pleural effusions, edema, hepatic encephalopathy (increased ICP & cerebral edema), hyperdynamic CV system (increased CO & HR, decreased SVR), hepatopulmonary syndrome (decreased PaO2, intrapulmonary shunting), pulmonary HTN, hepatorenal syndrome, increased risk of bleeding & clotting & thrombocytopenia
|
|
|
What are pulmonary artery catheter values with pulmonary HTN?
|
Mean PAP > 25
PVR > 120 PCWP > 15 |
|
|
What procoagulants are decreased with end-stage liver disease?
|
Factors II, V, VII, IX & X
|
|
|
What anticoagulants are decreased with end-stage liver disease?
|
Proteins C & S, antithrombin III
|
|
|
What is important during preoperative assessment of the patient receiving liver transplant?
|
Echo, PFTs, renal function tests, coags & T&C
|
|
|
What are some anesthetic considerations for the patient receiving liver transplant?
|
Arterial line, 2-3 large bore IVs, central line, PAC, thoracic epidural?, immunosuppressives, PRBCs, FFP, plts, cryo, RSI, OG & temperature managment
|
|
|
What is the dissection phase of liver transplant?
|
Stage 1, mobilizes liver lobe & vascular structures
|
|
|
What is the anhepatic phase of liver transplant?
|
Stage 2, remove native liver & implant donor liver
|
|
|
What is the neohepatic phase of liver transplant?
|
Stage 3, reperfusion (anastamoses) & hemostasis
|
|
|
When can a patient undergoing liver transplant experience hypotension?
|
With liver manipulation & ascites decompression
|
