NUR 838 Abdominal Procedures Study Guide PDF

Abdominal Procedures Wide Variety o Organs o Patient characteristics ▪ dz, comorbidities (CA) o Conditions ▪ emergency conditions ▪ chronic conditions o Diagnoses o Procedures ▪ open vs. laparoscopic vs. robotic o Methods Abdominal Procedures: Open o Discuss anesthetic consideration and plans with o...

Abdominal Procedures Wide Variety o Organs o Patient characteristics ▪ dz, comorbidities (CA) o Conditions ▪ emergency conditions ▪ chronic conditions o Diagnoses o Procedures ▪ open vs. laparoscopic vs. robotic o Methods Abdominal Procedures: Open o Discuss anesthetic consideration and plans with open abdominal procedures. ▪ Why do we care? volume loss → hypovolemia infection invasive → painful → higher risk ▪ Approach or incision? organs involved pain control methods ▪ Patient’s preexisting condition and comorbidity? cardiac dz → open abdomen will affect preload, cardiac filling ▪ Anesthetic considerations—open procedures regional anesthesia for abdominal organs Common Abdominal Incisions Fluid & Electrolyte Imbalance o What are the causes? ▪ hyper- or hypovolemia ▪ medications (diuretics) ▪ disease processes (SIADH, DI, CKD) ▪ vomiting/diarrhea ▪ insensible losses ▪ NPO status (decreased intake) o How do you assess this? ▪ lab work—CMP ▪ tachycardia ▪ skin turgor ▪ UOP ▪ BP, orthostatic hypotension o Any plans of care? ▪ optimize electrolytes prior to surgery ▪ IVF ▪ replace electrolytes ▪ anemia → blood products ▪ spinal contraindication → hypovolemia N/V Review o Where does vomiting center reside? medulla, close to the 4th ventricle o What 3 most sensory inputs to the vomiting center arise from? the vomiting center receives input from the CTZ, cerebral cortex, and labyrinthovestibular center/vestibular apparatus, GI tract o What type of medicines? ▪ ondansetron, dexamethasone, scopolamine o How these medicines work? ▪ ondansetron—5HT3 blocker ▪ dexamethasone—MOA unknown for PONV ▪ scopolamine—anticholinergic that antagonizes ACh muscarinic receptors in the CTZ o Any concern with any of these drugs? ▪ QT prolongation o Who has high-risk factors (Apfel et al. Prediction)? ▪ female, young, GYN procedures, obese o ----o Chemoreceptor trigger Zone (Area postrema) → 5HT3, NK-1, DA-2 o Vestibular apparatus → H1, M1 (muscarinic acetylcholine receptor M1) o ----o Prevention/Treatment of PONV ▪ Selectively blocks serotonin 5-HT receptors Ondansetron (Zofran), Granisetron (Kytril), Dolasetron (Anzemet) o Anzemet not commonly used anymore. ▪ Dopamine receptor antagonist Metoclopramide: increases GI motility and antagonizes dopamine receptors in the CTZ (Contraindication?) o Parkinson dz is a contraindication to Reglan. Droperidol (Inapsine, 0.625 mg) → less commonly used ▪ Neurokinin-1 (NK1) receptor antagonists Emond (Aprptant) ▪ Antagonizes histamine-2 receptor, also reduces gastric volume cimetidine (Tagamet) ranitidine (Zantac) famotidine (Pepcid) ▪ Anticholinergic: antagonizes acetylcholine muscarinic receptors in CTZ scopolamine ▪ Corticosteroids Decadron – mechanism of action is unknown ▪ What else can we give? 5HT3 antagonists, like Zofran DA-2 antagonists, like Droperidol Benadryl→H1 blocker Propofol (10-20mg) Phenergan/promethazine Ativan ▪ Pharmacologic: Which meds are concern with prolonged QT interval? Zofran/ondansetron Dolasetron Droperidol ▪ Nonpharmacologic method? P-6/Neiguan o Common GI Diseases and Procedures ▪ Esophageal Diseases Dysphagia o Recognize any classic symptom? sensation of food stuck in throat, difficulty swallowing Diffuse Esophageal Spasm o Autonomic nervous system dysfunction (Elderly Patients) o Pain mimics angina pectoris/responds to nitroglycerin o Drugs that lower esophageal sphincter(LES)Pr. ?? isosorbide, nifedipine ▪ Drugs that DECREASE LES tone: - Atropine and glycopyrrolate decrease LES tone via their anticholinergic effects. - Benzodiazepines (e.g., diazepam) decrease LES tone, although the mechanism is unknown. - Opioids decrease LES tone via opioid receptors in the esophageal myenteric plexus. - Volatile anesthetics also decrease LES tone. - Sodium nitroprusside causes a dose-dependent decrease in LES tone. - Nitroglycerines (e.g., isosorbide dinitrate, glyceryl nitrate) decrease LES tone. - Beta-agonists (e.g., salbutamol, terbutaline) decrease LES tone. - Propofol and dexmedetomidine do not decrease LES tone at the usual clinical doses. However, high doses are associated with a decrease in LES tone. ▪ Drugs that INCREASE LES tone: - Metoclopramide increases LES tone as a dopamine receptor antagonist. - Anticholinesterases (e.g., neostigmine, edrophonium) increase LES tone via acetylcholine. - Succinylcholine increases LES tone and also increases gastric pressures during fasciculations. The increase in LES tone from succinylcholine may be from contractions of the diaphragmatic crura, cholinergic mimetic effect, or a reflex increase in gastric pressure. - Nondepolarizing muscle relaxants have little effect or cause a modest increase in LES tone. - Antacids increase LES tone by increasing gastric pH. Histamine-2 blockers and proton-pump inhibitors have no effect on LES tone. Achalasia o Degeneration of both the esophageal muscles/nerves and leading to LES dysfunction o Prevents sphincter relaxation, contractions, peristalsis of the esophagus o Dysphagia, Regurgitation → aspiration, malnutrition, weight loss Gastroesophageal Reflux Disease (GERD) ▪ Intragastric pressure ▪ LES Pressure ▪ What is barrier pressure? 28-29 mmHg at rest (normal) resistance to GE reflux; difference btwn LES pressure and gastric pressure gradient must remain positive to prevent LES opening o What is happening in resting tone of LES with GERD? ▪ The resting tone of the LES with GERD is lowered to about 13 mmHg → LES hypotension Effect of Anesthetic drugs on LES tone o What drugs decrease effect on LES tone? ▪ Opioids → decreases LES tone ▪ Propofol → no effect on LES tone (at normal doses); decrease ▪ Atropine → decreases LES tone ▪ Succinylcholine → increases LES tone ▪ Neostigmine → increases LES tone ▪ **from OpenAnesthesia know chart below Increase Decrease Metoclopramide Prochlorperazine Edrophonium Neostigmine Succinylcholine Pancuronium Metoprolol α-Adrenergic stimulants Antacids Atropine, Glycopyrrolate Dopamine Sodium nitroprusside Thiopental Tricyclic antidepressants β-Adrenergic stimulants Halothane Opioids Propofol Hiatal Hernia o Herniation of part of the stomach into the thoracic cavity through the esophageal hiatus in the diaphragm Esophageal Diverticula o Outpunching's of the wall of the esophagus: ▪ Pharyngoesophageal (Zenker’s diverticulum) Mucosal Tear (Mallory-Weiss Syndrome) o Caused by vigorous coughing or vomiting; retching o Tear gastric mucosa near the squamocolumnar mucosal junction → upper GI bleed Barrett’s Esophagus o chronic degradation of the lower esophageal sphincter leading to regeneration of carcinogenic cells o precursor to esophageal cancer o caused by GERD o S/S: ▪ dysphagia ▪ reflux esophagitis ▪ retrosternal pain or heartburn ▪ weight loss o multifaceted treatment approach: ▪ PPIs ▪ H2 blockers ▪ surgery o risk factors: ▪ family hx ▪ male ▪ while ▪ age > 50 ▪ current or past smoker ▪ excess abdominal fat ▪ hiatal hernia o normal anatomy of the esophagus: ▪ 4 layers mucosa—3 layers submucosa muscularis propria aventitia o ▪ normal anatomy of the LES: ▪ smooth muscle at the end of the esophagus ▪ normally, closed and relaxes for passage of food ▪ creates a pressure gradient LES > intragastric pressure ▪ LES pressure normally 15-30 mmHg above intragastric pressure ▪ under vagal control ACh—excitatory NO—inhibitory o GERD: ▪ affects 20% of Americans ▪ 10-20% of those will develop Barrett’s esophagus ▪ ulceration & hemorrhage ▪ 3 mechanisms responsible for reflux: increased gastric pressure lower LES pressure transient relaxation of LES o surgery: ▪ EGD ▪ Nissen fundoplication ▪ esophagectomy Esophageal Procedures Cricopharyngeal myotomy Diverticulectomy Nissen fundoplication -- Nissen Fundoplication o Wraps top of the stomach around LES & reinforce LES o What is your concern with dilators? PERFORATION Surgical esophagomyotomy Esophagectomy o Minimally invasive (laparoscopic, thoracoscopic, robotically) o o o o o o o o Transthoracic Transhiatal --The stomach receives innervation from several sources: ▪ What are they? parasympathetic NS-Cranial/vagus nerve sensory vagal fibers (gastric secretions) SNS nerve fibers (splenic nerve, celiac ganglion) Excision of the lower esophageal sphincter (LES) Loss of vagal innervations of the stomach ▪ vagus nerve innervation is lost → gastric contents not drained well ▪ Flaccid stomach is situated in the thorax ▪ Drained only by gravity ▪ Denervated stomach requires a pyloroplasty to prevent gastric outlet obstruction --Gastric Outlet Syndrome ▪ Gastric outlet obstruction (GOO) ▪ What is gastric outlet syndrome? clinical syndrome characterized by epigastric abdominal pain and postprandial vomiting d/t mechanical obstruction that prevents stomach emptying anything that mechanically obstructs ▪ What causes this syndrome? mechanical obstruction malignancy (pancreatic cancer) surgery o Question: ▪ Your patient is schedule for repair of fractured femur. He has past surgical history of Esophagectomy. Do you have any anesthetic concerns? o high risk for aspiration How do you manage with this patient? o RSI o Esophagectomy Anesthetic Considerations ▪ Aspiration pneumonitis (Mendelson Syndrome) → ARDS gastric pH < 2.5 What are the S/S? o pulmonary edema o shock o hypoxia o cyanosis o wheezing, coughing ▪ Decreased oral intake → dehydration, hypovolemia, electrolyte abnormalities, malnutrition ▪ Any co-existing disease that you may concern? cardiomyopathy alcoholism cancer pancreatic dz ▪ Any injury you may aware? recurrent laryngeal nerve damage hoarseness ▪ Approach of surgical procedure Left thoraco-abdominal Upper abdominal Right chest ▪ Recurrent laryngeal nerve injury → Sx? hoarseness one side vs. bilateral o know the differences Esophagoscopy/Gastroscopy o Most common ▪ Colonoscopy ▪ Esophagogastroduodenoscopy (EGD) ▪ Sigmoidoscopy ▪ Endoscopic retrograde cholangiopancreatography (ERCP) o Esophagoscopy/Gastroscopy Anesthetic considerations ▪ Limited access to airway ▪ Bowel prep & prolonged NPO → hypovolemia ▪ Position: lateral ▪ Complications: Perforation of upper GI tract → GI bleeding Distension of GI tract → bradycardia → give Robinul, atropine o touching vagus nerve o Precedex—caution, will decrease HR → no reversal with ERCP → prone positioning; eye injury ▪ ▪ ▪ o ETT to secure airway Stomach Procedures Emergent o GI bleed or perforation Elective o Carcinoma or peptic ulcer disease Aspiration precautions (all considered full stomachs) Fluid & electrolyte imbalances Have blood products ready Polycythemia vs anemia o polycythemia: thickened blood o anemia o PTT needs to be completed. --- Post Gastrectomy Syndrome o Dumping Syndrome: ▪ What is it? entry of hyperosmolar gastric contents into the proximal small bowel, which results in a shift of fluid into the small bowel lumen → plasma volume contraction and acute intestinal distention rapid gastric emptying seeping into vessels S/S: dizziness, diarrhea, ▪ Cause by? surgery to stomach or esophagus o Alkaline Reflux Gastritis: ▪ What is the clinical triad? postprandial epigastric pain a/w N/V reflux of bile into stomach histologic evidence of gastritis Intestinal Procedures Respiratory insufficiency o Diaphragmatic impairment & splinting Volume & electrolyte imbalances Large 3rd space losses Aspiration risk and prophylaxis Avoid Reglan/metoclopramide with suspected obstruction --- Small Bowel Resection o Indication → intestinal obstruction, Crohn's disease, volvulus, intussusception, tumors, and abdominal trauma o Surgical and stapling techniques ▪ Incision → Transverse or vertical incision (vertical is more painful than transverse) The ends can be anastomosed by surgical and stapling techniques o Volume status and Blood loss ▪ Blood loss → 50-100ml ▪ Hypotension Sequestration of fluid in the abdomen Diarrhea, vomiting, prolonged NPO Status Which induction drugs are preferred choice? o Ketamine, Etomidate Large Bowel Procedures Hemodynamic instability possible o Pain o Risk of sepsis & shock Additional hypovolemia if febrile o Insensible losses Nasogastric tube preoperatively o Decompress stomach Bowel Procedures: Anesthetic implications o ▪ ▪ ▪ ▪ Severe abdominal pathology: ▪ Respiratory insufficiency, decreased FRC, hypoxemia ▪ Pain or impairment of diaphragmatic excursion ▪ Ascites, blood in the abdominal cavity ▪ Tumor, bowel distension o High risk for aspiration → treated as 'full stomach‘ ▪ RSI/CCP must o H2-receptor antagonists, sodium citrate ▪ famotidine, cimetidine, ranitidine; Bicitra o Bowel obstruction o What else? ▪ volume loss, blood loss ▪ heat loss → Bair Hugger, warmed fluids Ostomy Procedures Diverse population o Healthy o Critically ill Hypovolemia o Chronic low intake o Malnutrition May be on large doses of steroids → steroid replacements Evaluate hydration status Appendectomy Respiratory impaired to pain & splinting Perforation & sepsis risk → usually go to ICU postop Aspiration risk Potential for dehydration: o Fever o Emesis o Decreased intake Mesenteric Traction Syndrome Signs and symptoms: sudden tachycardia, hypotension, flushing, hypoxia, large amount of blood in one area Caused by release of prostaglandin from mesenteric area o prostacyclin release o prostaglandin levels increase as well Epidural / spinal anesthesia inhibits the transmission of afferent impulses from the splanchnic bed, but it does not affect prostacyclin release H1/H2 antihistamines:  incidence of cardiac dysrhythmias Ketorolac IV → treat flushing Large-dose phenylephrine (up to 15xs the usual dose) o usual dose: 100 mcg IV push o pure alpha-1 agonist Carcinoid Tumors What is Carcinoid tumor? o tumors that originate in the GI tract o secrete vasoactive substances and GI peptides o carcinoid tumors contain GI peptides--gastrin, insulin, somatostatin, motilin, neurotensin, tachykinins (substance K, substance P, neuropeptide K), glucagon, gastrin-releasing peptide, vasoactive intestinal peptide, pancreatic peptide, other biologically active peptides (corticotropin, calcitonin, growth hormone), prostaglandins, and bioactive amines (serotonin) Slow growing malignancies composed of enterochromaffin cells Mostly found in the GI tract (2/3 of cases) o Can also occur in lung, pancreas, thymus, and liver Capable of metastasis Secretion of vasoactive substances: o Serotonin* o Histamine* o Kinin peptides* o Corticotropin o Dopamine o Neurotensin o Prostaglandins o Substance P o Gastrin o Somatostatin o Pancreatic polypeptide o Calcitonin o Neuron specific enolase Histamine release= responsible for bronchospasm and may cause flushing Bradykinin release= causes vasomotor relaxation which causes severe hypotension and flushing, can also cause bronchospasm especially in asthmatics and frequently in patients with cardiac disease Serotonin: Adrenergic stimulation causes the release of serotonin into the circulation Elevated serotonin has many side effects: Vasoconstriction or vasodilation creating both hypertension and hypotension possibilities Both inotropic and chronotropic responses due to indirect effects from release of norepinephrine Increased gut motility Secretion of water, sodium, chloride, and potassium by the small intestines Vomiting Bronchospasm Hyperglycemia Prolonged drowsiness after emergence from anesthesia 24- hour Urine Sample Elevated 5-HIAA (metabolizes serotonin) 🡪 marker for excess serotonin production 🡪 carcinoid tumor is present What is Carcinoid syndrome? o Result of large amounts of serotonin and vasoactive substances that reach systemic circulation from the carcinoid tumor o Occurs in approx 10% of patients with carcinoid tumors & is a result of the large amounts of serotonin and vasoactive substances reaching the systemic circulation o 2 most common signs: flushing and diarrhea (dehydration and electrolyte abnormalities) ▪ Sudden onset of flushing ▪ Physically it appears as a deep red blush, especially in the neck and face, often associated with a feeling of warmth and occasionally associated with pruritus, tearing, diarrhea, or facial edema ▪ Hypotension and hypertension can occur, as well as bronchoconstriction ▪ Flushes precipitated by stress, alcohol, exercise, certain foods, and drugs (catecholamines, pentagastrin, and serotonin reuptake inhibitors) ▪ Wheezing, asthma-like presentation ▪ Pellagra Occurs if these substances reach systemic circulation without being metabolized by the liver Life threatening perioperative hemodynamic instability 30 mg/24 hr urine sample. Normal range is 3-15 mg/24 hr (most frequently ordered) o Also, diagnosis can be confirmed by: plasma or urine serotonin concentrations (false-positives may occur) ▪ Some foods contain serotonin (kiwi, pineapple) o 5-hydroxyindoleacetic acid Tumors typically secrete GI peptides and/or vasoactive substances o Serotonin, Kallikkren, Histamine, Substance P 70% : a bronchus, the jejunoileum, or the colon-rectum, appendix ▪ Carcinoid Syndrome o Carcinoid syndrome (20%) of patients with carcinoid tumors o Large amount of serotonin/vasoactive substances to systemic circulation ▪ Histamine and serotonin o Two most common signs are flushing and diarrhea o What other symptoms? ▪ cutaneous flushing ▪ diarrhea ▪ tachycardia ▪ dyspnea, wheezing, bronchospasm ▪ hypotension or hypertension ▪ Pellaga-like skin lesions ▪ hyperglycemia ▪ pulmonic stenosis, tricuspid regurgitation ▪ primarily right-sided valvular heart dz ▪ CV involved in 50-60% ▪ bronchoconstriction ▪ facial edema Carcinoid Tumors Cont’d o Carcinoid triad: ▪ 1. flushing ▪ 2. diarrhea ▪ 3. cardiac involvement (R sided HF) o The cause of most of these signs is serotonin. o How do you treat this? ▪ H1/H2 blockers ▪ 5HT3 blockers ▪ Somatostatin analogues – octreotide/sandostatin Carcinoid Tumors Treatment o 5HT1 /5-HT2 receptor antagonists (methysergide, cyproheptadine, ketanserin) to control diarrhea o 5-HT3 receptor antagonists (ondansetron, tropisetron, and alosetron) can control diarrhea and nausea o H1- and H2-receptor antagonists (diphenhydramine, cimetidine or ranitidine) o Synthetic analogues of somatostatin (octreotide, Lanreotide) Carcinoid Tumors Management of Anesthesia o Drugs MAY PROVOKE Mediator Release ▪ Can you name them? succinylcholine, mivacurium, atracurium, tubocurarine, epinephrine, norepinephrine, dopamine, isoproterenol, thiopental want to avoid ketamine → SNS stim o Arterial blood pressure monitoring: rapid changes in hemodynamics o Octreotide: preop & before manipulation of the tumor: attenuate o General anesthesia? INCREASES levels of serotonin o Epidural analgesia safe → if treated with octreotide o Antiemetic choice? ondansetron Case Study 1 A 68-year-old man is scheduled for an emergent exploratory laparotomy. Two weeks previously he had undergone a right hemicolectomy. He now presents with a 2- day Hx. of severe abdominal pain, increasing abdomen distention, and the absence of passing wind and/or defecation. He is otherwise healthy. He is NPO for 14 h. He weighs 68 kg and 5 ft 9 in. His airway is classified as MPI. o ▪ What would you include in your preoperative evaluation of this patient? ▪ CBC, CMP, KUB ▪ fluids ▪ VS ▪ comorbidities o Discuss your anesthetic plan. ▪ RSI ▪ Lidocaine 70 mg ▪ Propofol 100 mg ▪ Anectine 70 mg ▪ GETA o Any preop medications? Any contraindication med? ▪ Avoid N2O and Reglan ▪ Avoid opioids o What medications will you use for induction and maintenance of anesthesia? ▪ Lidocaine 70 mg ▪ Propofol 100 mg ▪ Anectine 70 mg ▪ Sevoflurane o How will you manage postoperative pain in this patient? ▪ Avoid opioids → slows gastric emptying ▪ Consider Toradol, Ofirmev Rapid sequence induction is uneventful, and the endotracheal tube is inserted into the trachea and secured. The surgeons request a nasogastric (NG) tube. However, you find you are unable to pass the NG tube into the esophagus. o What will you now do to get the NG tube into the stomach? ▪ Head flexion, use gloved finger to guide NGT ▪ GlideScope blade Liver Procedures Evaluate liver function Hepatitis status o Active o Chronic Large blood loss anticipated o T & C, have blood in OR o Rapid infusion device o Blood salvage techniques if not cancer >90% develop respiratory complication Coagulopathy: Which test? PT/INR, aPTT o Thromboelastography (TEG) → looks at relationship to platelets ▪ https://onlinelibrary.wiley.com/doi/10.1002/ajh.23599 ▪ know DIC panel components Liver resection o Indication: ▪ Removal of primary liver tumors and metastatic tumors to the liver ▪ ▪ ▪ Hepatocellular carcinoma (HCC) → most common primary liver tumor ▪ Metastases from colorectal cancer → most secondary tumors ▪ Cirrhosis d/t chronic alcohol abuse and chronic hepatitis B, C o Intraop blood loss → most important predictor of short-term survival o Majority of bleeding: injured Intrahepatic branches of hepatic and portal veins o To minimize blood loss → Pringle maneuver ▪ What is Pringle maneuver? hepatoduodenal ligament is clamped with either a hemostat or by hand 3 vessels: hepatic artery, portal vein, common bile duct this limits blood flow through the hepatic artery and the portal vein → controls bleeding from liver and common bile duct ▪ Anesthetic management during this maneuver? monitor blood loss, reperfusion injury, hypotension, blood transfusion needs, ischemia, venous air embolism VS changes o Factors of morbidity and mortality: ▪ liver fx ▪ extent of surgery ▪ surgeon experience o Postoperative complications of liver resection: ▪ Pulmonary insufficiency ▪ DIC, Hemorrhage ▪ Hypoglycemia ▪ Hypothermia ▪  liver function ▪ Electrolyte imbalances Biliary Tract Surgery Sphincter of Oddi o Spasm r/t narcotics o What could you give? ▪ glucagon ▪ naloxone ▪ NTG ▪ atropine ▪ CCB or BB Atelectasis from splinting/pain PT/PTT abnormal w/obstructive: o Jaundice o What could you give? Vitamin K, FFP Aspiration prophylaxis Splenic Surgery What type of trauma is most commonly a/w splenic injury? o blunt trauma to abdomen Most common indication for an open splenectomy: o traumatic laceration to spleen Procedures are performed during a staging laparotomy: o A splenectomy, needle and wedge biopsies of the liver o Biopsies of the celiac, periaortic, portahepatic o Mesenteric lymph nodes Indications: o Idiopathic thrombocytopenic purpura (ITP): 60% of the patients o Thrombotic thrombocytopenic purpura (TTP) ▪ blood not clotting normally ▪ immune disorder o Adenocarcinoma o Hereditary spherocytosis → sphere-shaped, not normally functioning o Hypersplenism o Hemolytic anemia o ▪ ▪ ▪ Neuroendocrine islet cell tumors ▪ Insulinomas → secretes insulin excess insulin production ▪ Gastrinomas → secretes gastrin Absolute Contraindication: o Massive splenomegaly (spleens measuring > 30 cm longitudinally) Pancreatic Surgery Position: o On a beanbag in full right lateral or 45-degree decubitus position o The kidney rest is elevated & table should be flexed Complications: o Adenocarcinoma is associated with hypercoagulability ▪ Measures to prevent DVT and pulmonary embolism SCDs o What happens blood sugar following a total pancreatectomy? ▪ brittle/unstable diabetes, difficult to control ▪ type 3c diabetes o Volume status? ▪ bleeding → hypovolemia --- Pancreatic Surgery Whipple Procedures o Whipple Resection is comprised of: ▪ Pancreaticoduodenectomy Gastrojejunostomy Hepaticojejunostomy Pancreaticojejunostomy o What are common preop diagnoses seen in patients w/ Whipple procedure? ▪ chronic pancreatitis alcoholism ▪ pancreatic cancer o Indications: ▪ Chronic pancreatitis, pancreatic cancer, malignant cystadenomas o Contraindications: ▪ Peritoneal or liver metastases ▪ Tumor infiltration into root of the mesentery ▪ Superior mesenteric vessel involvement → excessive bleeding ▪ Hepatic artery involvement Pancreatic Procedures Anesthetic Consideration o Respiratory involvement ▪ pleural effusion, atelectasis & ARDS progressing to failure in up to 50% of pts with acute process o Severe electrolyte disturbances (K+) o Glucose monitoring o Major fluid shifts & losses ▪ warmed fluid/blood Peritoneal procedures (Herniorrhaphy) Emergency surgery for hernias o Obstructed o Strangulated o Incarcerated → other areas involved Aspiration risk Fluid & electrolyte status Regional anesthesia? o TAP block?? Couldn’t find anything o good for pain, relaxation Trauma Laparotomy What are your anesthetic concerns? o bleeding o fluid losses/volume status ▪ ▪ ▪ o infection o hypothermia (heat loss) o aspiration risk (full stomach) o multiorgan involvement o perforation o hemodynamic stability o **need blood ready o baseline condition Anal/Rectal Surgery Rectal prolapse (Procidentia) o Intussusception of the entire thickness of the rectal wall past the anal canal o Often associated with anal incontinence Perianal fistulae Anesthetic Concerns? o prone or lithotomy positioning ▪ high lithotomy ▪ prone → ETT o volume status o hemodynamics Causes of rectal prolapse: o Pudendal neuropathy o Spina bifida o Decreased pelvic muscular support o Chronic constipation and straining o Congenital deficiency of rectal support o Cystic fibrosis o Acute parasitic diarrheal illness Cause of perianal fistulae: o Infection of the anal glands that are located within the rectal wall (primary) o Crohn's disease o Trauma o Neoplasms/cancer o Radiation therapy o Inflammation of the peritoneal cavity Case Study 2 A 27-year-old woman in the ER complaining of N/V, pain in right lower quadrant of the abdomen. Based on her H/P and findings suggestive of acute appendicitis seen on abdominal CT scan, she is scheduled for emergency appendectomy. She is otherwise healthy and takes no regular meds. Her surgical history includes a dilatation and curettage (D&C) at age 25. She has not had problems with previous anesthetics. o What would you include in your preoperative evaluation of this patient? ▪ CBC, CMP (electrolytes) ▪ family anesthetic hx (MH, PCE) ▪ current pregnancy status ▪ NPO status o What medications will you use for induction and maintenance of anesthesia? ▪ RSI → lidocaine, propofol, anectine ▪ Maintenance with sevoflurane, PRN fentanyl 50-100 mcg, ketamine 10 mg PRN Case Study 3 You have just completed patient who has defibrillator pads during operation of liver resection. Prior to closing, the instrument count revealed two missing laps. The OR staff conduct an extensive search and find one in the trash. The surgeon again examines the abdomen for the missing lap but can’t find it. Both an abdominal and CXR is done in the OR. The radiologist calls into the room and states he can’t identify any retained objects. The incision is closed, and the pt is transported to the ICU. A routine CXR taken the next AM, shows clearly a retained lap in the upper abdomen Questions : o How can this happen? ▪ mistake in counting ▪ fatigue/long hours ▪ ▪ fast turnover/pressure for fast turnover ▪ lap has a magnet in it that blocks the xray o Why was it not spotted last night in the operating room? ▪ positioning/shifting Commonest cause of retaining foreign bodies When reviewing the literature…. o In change of scrub nurses’ shift o Team fatigue o Staff shifts with sloppy handovers o Surgeon declines recount o False-negative XR o Bloody procedures o Conversations in the OR Practice Questions: Carcinoid Tumor Choose AVOID or SAFE for the following medications. 1. Atracurium = AVOID (histamine releasing) 2. Morphine = AVOID (histamine releasing) 3. Octreotide = SAFE (primary tx) 4. 5-HT3 antagonist = SAFE (blocks serotonin) 5. Succinylcholine = AVOID (fasciculations/releases histamine) 6. Antihistamines = SAFE (inhibits histamines) 7. Ketamine = AVOID (stimulates SNS) 8. Meperidine = AVOID (histamine releasing) Which medications are best for treating hypotension? SELECT 2. A. Phenylephrine B. Ephedrine C. Vasopressin D. Norepinephrine ANSWER: A & C