Anesthesia for Robotic Procedures & Steep Trendelenburg
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| The initial use of robotic surgery was intended for what type of procedure? | Prostatectomy
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| What are some advantages of robotic procedures? | reduced blood loss, reduced tremor (surgeon), greater scale of hand movements, greater hand eye coordination, 7 degrees of freedom of the instruments, surgeon can sit (reduced fatigue), 3D HD vision, greater depth perception
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| What are some disadvantages of robotic procedures? | higher cost, lengthy set up and patient prep, inefficient for some surgery types, requires bigger OR, tracer placement not cosmetically favorable, limited direct access to patient, no feedback regarding tactile force, not easily converted to open case
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| What 3 primary factors, known as the triple threat, alter physiology? | lithotomy, abdominal insufflation (pneumoperitoneum), steep trendelenburg
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| What is the definition of steep trendelenberg? | > 30 degrees, with a maximum of 45 degrees
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| What types of surgeries are usually performed in the maximum trendelenberg position? | prostate and GYN
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| The diaphragm can shift cephalad in trendelenberg by as much as _______ | 8 - 10 cm
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| PIPs can increase by as much as ____ in steep trendelenberg. | 50%
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| What do some recommend insufflation pressures stay under in order to optimize an already weakened pulmonary compliance? | 12 mmHg
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| The pulmonary system is affected by insufflation in two ways, What are they? | increased intra-abdominal pressure and CO2 acting as a drug
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| What ventilation mode is more appropriate and efficient with patients in steep trendelenberg, pressure control or volume control? | pressure control (lower PIPs and higher dynamic compliance)
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| In pressure control ventilation, what can occur if the pressure is set too low? | inadequate tidal volume
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| Explain how volutrauma can occur when the pneumoperitoneum is deflated. | Pressure control ventilation set to higher pressures r/t pneunoperitoneum. Once this pressure taken away, greater tidal volume allowed, which when excessive can lead to volutrauma.
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| Steep trendelenberg can lead to a 35% _______ in MAP and a 3 % ________ in CVP. | increase; increase
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| Does SVR increase or decrease in steep trendelenberg? | increase
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| Does cardiac output increase or decrease in steep trendelenberg? | decrease (up to 50%) r/t decrease in HR and decrease in SV
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| Increased SVR also leads to __________ sympathetic nervous system outflow and activation of the _______________ system | increased; renin-angiotensin-aldosterone system
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| Are the cardiac arrhythmias that occur in steep trendelenberg most likely to be bradycardia related or tachycardia related? | bradycardia....r/t increased vagal tone and hypercapnia
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| What should be suspected if sudden CV collapse occurs along with capnograph changes in a patient during a laparoscopic/robotic steep trendelenberg case? | CO2 gas embolism (more common during insufflation or dissection of deep venous tissue)
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| What 4 factors can increase the risk of developing a CO2 gas embolus? | CO2 > 50 mmHg, 6 or more ports, operative time > 200 minutes, older patient
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| What could cause shoulder pain after a lap or robotic procedure? | residual CO2 irritating phrenic nerve
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| Does the pneumoperitoneum have any effect on the renal system? if so what? | yes; compression of renal vasculature can lead to decreased UOP, creatinine clearance, GFR, RBF
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| In healthy patients, what does the research tell us about cerebral ischemia risk in steep trendelenberg with pneumoperitoneum? | conflicting; MAP increase may lessen effects of increased CBF and ICP
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| In patients with cerebral vascular disease or already increased ICP, what does the research say about their risk for cerebral ischemia in steep trendelenberg with pneumoperitoneum? | risks are increased for these patients
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| What is the preferred method for securing a patient in steep trendelenberg? | x pattern of chest straps (shoulder straps/braces can cause brachial plexus injuries)
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| What is the most common complication from lithotomy position? | common peroneal nerve injury
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| Prolonged lithotomy and steep trendelenberg leads to hypo perfusion of lower extremities comparable to ________________ | compartment syndrome
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| What is the most common ocular complication from lithotomy or steep trendelenberg surgery? | corneal abrasions
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| A high degree of facial and conjunctival edema in a patient may indicate _______________ | laryngeal edema
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| What is the ETT leak test and why would it be used? | deflate cuff and ensure that Vt decreases > 15% before extubating to test for laryngeal edema
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Created by:
Mary Beth
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