Term
| What are the symptoms of mesenteric traction syndrome? |
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Definition
| Sudden tachycardia, hypotension, and cutaneous hyperemia |
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Term
| What causes the symptoms of mesenteric traction syndrome? |
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Definition
| When the mesentary is retracted, there can be a sudden release of prostaglandin (PG12) that causes vasodilation and a release of histamine. |
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Term
| What can be used to treat or prevent mesenteric traction syndrome? |
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Definition
| Anti-inflammatory drugs, or the prophylactic use of H1 and H2 blockers. |
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Term
Why is the use of nitrous in bowel surgery questionable?
A linear correlation exists between the length of nitrous exposure and dose administered and what? |
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Definition
Because nitrous is 30X more soluble than nitrogen, and nitrous expands (use of 80% nitrous can lead to a 5 fold increase in bowel size!)
Bowel cavity size |
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Term
| What is the name for slow growing, benign tumors usually found in the bowel? |
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Definition
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Term
| What is the difference between nonmetastatic and metastatic carcinoid tumors? |
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Definition
Nonmetastatic tumors secrete hormones or vasoactive peptides which travel to the liver and are typically deactivated.
Metastatic carcinoid tumors secrete vasoactive substances directly into general circulation (seratonin, bradykinin, histamine). |
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Term
What is the carcinoid triad?
What are the other symptoms? |
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Definition
flushing, diarrhea, bronchoconstriction
upper body flushing, hypo or hyper tension, carcinoid heart disease |
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Term
What is involved in carcinoid heart disease?
What is key in managing carcinoid tumors? |
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Definition
pulmonary vein stenosis or tricuspid valve regurgitation (essentially right heart failure)
Avoid techniques that cause the tumor to release the substances--emotional stress can trigger the release of vasoactive substance, histamine releasing drugs should be avoided, catecholamines can enhance the release of the substances |
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Term
What are surgical considerations for carcinoid tumors?
What is the antiemetic of choice and why? |
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Definition
Surgical manipulation can lead to a massive outflow of these substances, so an A-line and central monitoring should be considered.
Hyper or hypoglycemia can occur.
Zofran--it is a seratonin inhibitor 5HT3 |
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Term
| What are the benefits associated with the smaller incisions with laparoscopic surgeries? |
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Definition
| less pain, less post-op pulmonary impairment, reduction in ileus, shorter stays, and early ambulation |
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Term
| Why is CO2 the gas of choice for laparoscopy? |
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Definition
| It is colorless, inexpensive, does not support combustion, and provides less opportunity for an air embolism to develop d/t it favorable solubility profile in blood and quick elimination through the lungs. |
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Term
| The Veress needle is inserted into the umbilicus--what structure lies directly beneath the umbilicus? |
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Definition
| Aortic bifurcation--especially if the patient is in trendelenberg |
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Term
What intraabdominal pressures (insufflation pressure) should be maintained? Why?
What is the cardiac profile associated with normal insufflation? |
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Definition
Less than 15 mmHg... pressures >15 begin to have adverse hemodynamic effects.
Increased SVR, MAP, CVP and PaOP.
Decreased CO--biphasic. CO normally decreases with insufflation but returns to normal within 10-15 minutes.
Unless hypercapnea or catacholamine release is present, the heart usually does not change. |
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Term
| What are the respiratory changes associated with laparoscopy? |
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Definition
1. Reduction in lung volumes
2. Decreased compliance
3. Increased peak airway pressures
4. Reduction in FRC (worse in trendelenberg)
5. Hypoxemia d/t reduction in FRC and V:Q mismatching
6. Increased ETCO2 |
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Term
What is the pattern associated with the increased CO2 in lap. surgery?
What should you consider re: pts with severe pulmonary disease and ETCO2? |
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Definition
As the CO2 diffuses from the abdominal cavity into the blood, the ETCO2 will gradually rise, then peak and remain steady 15-30 min after insufflation.
They do not eliminate CO2 properly, and the ETCO2 may not be a reliable indicator of the arterial PCO2. This is bad as hypercapnea can lead to acidosis and decreased inotropy! |
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Term
| What are anesthetic considerations associated with lap. surgery? |
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Definition
Mostly limited to general anesthesia--pelvic cases are low, and LMAs may work
Usually use ETT with controlled mechanical ventilation
Probably want OG/NG
Paralysis of belly wall
Nitrous may not be the best choice |
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Term
| What drugs in anesthesia can cause a spasm in the sphincter or Oddi? Why is this bad, and what can we do to treat it? |
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Definition
| Narcotics--if this happens during intraop. cholangiograms, it can lead to misinterpretation of the results. Treat the spasms with glucagon, naloxalone, or nitroglycerine |
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Term
What type of pain is associated with lap chole, and what is the best management?
What about PONV? |
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Definition
intraabdominal, incisional, and shoulder pain--multimodal treatment including narcs and NSAIDS
PONV is common--reducing opioid with NSAIDS can help, and plan on using antiemetics |
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Term
What type of vascular complications can happen in laparoscopic surgeries? What should flag suspicion?
What other structures may be injured? How does the case change if one of these complications occurs? |
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Definition
Placement of the Veress needle or trocar can puncture the aorta, iliac arteries, IVC. Unexplained hypotension.
Hepatic, splenic, mesenteric tears, or bowel or bladder perforation. Immediate conversion to open case. |
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Term
| What type of arrhythmias may be associated with lap. surgeries? What might trigger them? |
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Definition
| Bradycardia, cardiac arrhythmias, or asystole--hypercapnea or increased vagal tone d/t peritoneal stretching |
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Term
| What happens if the Veress is not placed in the peritoneal space? What will we see? What should we do? |
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Definition
| Inadvertent insufflation of SQ tissue will occur, leading to extensive SQ emphysema and a sudden rise in ETCO2. Ventilation to remove the CO2. Condition resolves once belly is deflated. |
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Term
If the insufflated CO2 sneaks around the aortic or esophageal hiatus, what might happen?
How might this present? |
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Definition
Pneumothorax, pneumomediastinum, pneumopericardium. Tension pneumo can be life threatening.
Unexplained rise in peak airway pressures, tracheal deviation (if tension pneumo), decreased sats. CXR to confirm. |
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Term
| What might happen with direct insufflation into a vessel? |
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Definition
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