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Gyn & lap surgery
Clinical exam 2 - Gyn & lap surgery
Question | Answer |
---|---|
What is a hysteroscopy (slide 2-1)? | inside of the uterus is fiberoptically visualized by dilating w/ gas (CO2) or fluids (LR or glycine) |
2 Advantages of laparoscopy are (slide 2-2): | less pain, less pulm dysfxn postop |
What are some adverse effects of laparoscopy (slide 2-3)? | hypercapnia, increases resistance (PIP) to ventilation, hypoxia d/t V/Q mismatch & decreased FRC; arrhythmias (vagal stretching = brady); low cardiac output; organ or blood vessel puncture w/ gas embolism and/or hemorrhage |
What should be the pressure of the machine delivering the gas used for insufflation (slide 2-3)? | should be less than 15 mmHg |
Physiologic complications of pneumoperitoneum are caused by these 3 principle things (slide 3-1): | mechanical pressure, neurohumoral substance release (vasopressin, renin, norepi, dopamine) |
Hemodynamic change to SVR d/t pneumoperitoneum is (slide 3-2): | SVR increases (d/t renin, vasopressin, & mechanical compression of intra-abd vessels) |
Hemodynamic changes to CVP d/t pneumoperitoneum are (slide 3-2): | CVP increases (if IAP <20 mmHg) or decreases (if IAP >30 mmHg) & is confounded by position & intravasc volume status. probably d/t mechanical pressure on abd vessels |
Hemodynamic change to stroke volume d/t pneumoperitoneum are (slide 3-3): | reduced, probably d/t increased afterload & decreased right filling pressures (preload) |
Hemodynamic change to cardiac output d/t pneumoperitoneum are (slide 3-3): | complex, variable, usually decreased; depends on position, hydration, amount of IAP; CO may increase d/t neurohumoral factors (renin & vasopressin) & increased HR |
Hemodynamic change to BP d/t pneumoperitoneum are (slide 3-3): | usually increases concurrent w/ increased SVR |
What causes arrhythmias during laparascopy (slide 4-2)? | reflex increases of vagal tone may result from sudden stretching of peritoneum & electrocoagulation of fallopian tubes |
What types of arrhythmias may occur during laparascopy (slide 4-2)? | bradycardia, cardiac arrhythmias, & asystole |
What accentuates vagal stimulation during laparoscopy (slide 4-2)? | if level of anesthesia is too superficial or if pt is taking beta blockers |
What is the treatment for arrhythmias that may occur during laparascopy (slide 4-2)? | interruption of insufflation, atropine, & deepening of anesthesia after recovery of heart rate |
During laparascopy, when do cardiac irregularities most likely occur (slide 4-3)? | early during insufflation, when pathophysiologic hemodynamic changes are the most intense |
What can high insufflation pressures do to EKG (slide 4-3)? | QT prolongation |
During CO2 pneumoperitoneum, how long does it take for PaCO2 to reach plateau (slide 5-1)? | 15 - 30 min after the beginning of CO2 insufflation |
Hypercapnic levels > 50 mmHg may cause (5-1): | arrhythmias, increased cerebral blood flow & ICP, peripheral vasodilation, pulm vasoconstriction |
A significant rise in PaCO2 during laparoscopic procedure may be due to: | CO2 SQ emphysema |
Treatment for SQ CO2 emphysema due to lap procedure is: | temporarily interrupt insufflation to allow CO2 elimination & resume after correction of hypercapnia using lower insufflation pressure, controlled mechanical ventilation until hypercapnia is corrected (esp COPD pts) |
CO2 in the pleural space is called: | capnothorax |
The most feared and dangerous complication of laparoscopic surgery is: | gas embolism |
What injuries may occur from lithotomy position? | common peroneal nerve, saphenous nerve (pressure over medial tibial condyle), sciatic nerve may be stretched by hyperflexion of hip & extension of knee, popliteal fossa compression |
When pt is placed in trend/steep trend, what intervention must be done w/ ETT? | check bilateral breath sounds to make sure ETT did not move during reposition |
complications of head down positioning combined w/ pneumoperitoneum are: | V/Q mismatch (hypoxia, etCO2 + paCO2); shunt, deadspace |
If LMA will be used for lap surgery, what is the 15 rule that must be followed? | no more than 15 degrees head down, 15 in, 15 cm H2O IAP |
What level of neuraxial blockade is indicated for pelvic cases? | T6 - T8 |
What part of the brain does oxytocin come from? | posterior pituitary |
Fast infusion of oxytocin may cause (4 things): | vasodilation, hypotension, flushing, reflex tachycardia |
Oxytocin is structurally similar to _____ and high doses may cause _______ | ADH; water retention |