Anesthesia Mgmt: Prostatectomy – Flashcards
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Where is the prostate anatomically located?
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Located between the bladder and urethra
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What is the criteria for Robotic Assisted Laproscopic Radical Prostatectomy?
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Type of cancer = localized disease stage T2c or less Lap/robotic availability Surgeon experience and skills
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What do you prepare for this surgery?
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SCOMLADI Anesthesia machine check Monitor/equipment functioning
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Preoperative assessment?
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Physical assessment Airway assessment IV access (18g, A-line, CL) Comorbidities Lab values H/P ASA Consent
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What meds can you give preoperative for anxiety?
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Versed
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What are some OR pre-incision considerations?
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Prophylactic ABX (Ancef 1 g) NEAR prepared and ready Equipment (Blade, ETT, Ambu, oral/nasal) Pre-oxygenate with 100% O2
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What type of Anesthesia are we going to use with this
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RSI/GETA Strongly consider an oral gastric tube
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How do we manage these patients?
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Nerve stimulator = 2-3 twitch + volatile = approp. relax Face/Eye protection (protect from corneal abrasion) Balance anesthesia (VA + narc + NMB) Vecuronium = 24-30 min DOA Titrate to effect during surgery Assess IV
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Initially, what position is this patient placed in? What will be the final position?
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Supine/Lithotomy Extreme trendelenburg w/arms tucked (lower legs in lithotomy prior to trendelenburg
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What is the average length of surgery?
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1-3 h depending on skill
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What vent settings do you want to use post-incision?
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Switch to PC ventilation (insufflation) CO2 10-15 mmHg
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If a patient develops pneumoperitoneum during surgery, what happens to the cardiovascular system?
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↑ IAP → ↓ Venous Return → ↓ Preload → ↓ CO & ↑HR, MAP, SVR, & PVR When coupled with the trendelenberg position, the effects are compounded
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What are 3 renal complications to consider?
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Studies have identified 35-60% reduction in RBF as a result of abdominal insufflation ↓ CO leads to activation of the RAAS Oliguria = proportional to the amount of pressure and length of a pneumoperitoneum
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What are some cardiac effects?
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Patients with cardiac disease are at increased risk as a result of the stress placed on the hemodynamic system Hypovolemic shock
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What is the ventilator setting during maintenance?
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Volume control OR Pressure control
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How do you calculate Vt?
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6-10 ml/kg
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How do you calculate estimated blood loss?
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ABL = EBV x (Hct pre-op - Hct post op) / Hct pre-op
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How do you calculate EBV?
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Males 75 ml/kg Females 65 ml/kg Children 1-2 years 75 ml/kg Neonate at term 85 ml/kg Premature infants 90 ml/kg
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Where should the MAP be for prostatectomy?
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MAP 70-110 with pressor (usually NEO) until the urethral anastomosis is complete
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Once anastomosis is complete, rapidly replace what?
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Fluid volume
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What is Indigo Carmine and what is it used for?
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Injection used to find ureteral orifices during cystoscopy and ureteral catheterization. It is a diagnostic agent that tests for renal function. Common side effects include a mild rise in blood pressure. Indigo Carmine solution is injected either intravenously or intramuscularly, and its appearance at the ureteral orifices is watched with the cystoscope in place
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What are the 2 reversal agents used for emergence and what do we combine them with to prevent side effects?
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Neostigmine + glycopyrrolate Edrophonium + Atropine Use nerve stimulator
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What are 4 different actions we take during emergence?
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Zofran Suction oral pharynx Stop N2O and VA and give 100% O2 Extubate once protective reflex return and patient able to respond to verbal commands
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What 3 things do we assess and document (other than respiratory) post-op?
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Injuries (pressure points, SQ emphysema) Pain H/H - if excessive blood loss
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What 2 drugs do we give for pain management?
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Ketorolac + Opioid
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Da Vinci Prostatectomy Presentation Questions-Willie McCorvey 1. Face & eye protection are rarely used for patients undergoing a robotic prostatectomy. (T or F)
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False
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2. Surgical positioning for a robotic prostatectomy includes which of the following? a. Supine/lithotomy for trocar placement b. Extreme trendelenburg with arms tucked c. Extreme reverse trendelenburg with arms tucked d. None of the above
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Supine/lithotomy for trocar placement Extreme trendelenburg with arms tucked
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3. Which of the ventilator modes help towards limiting peak airway pressure once the pneumoperitoneum has been established? a. Volume ventilation b. Assist control c. Control mode d. Pressure control mode
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Pressure Control Mode
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4. What physiological changes should be anticipated with abdominal insufflation? a. Decreased venous return b. Decreased preload c. Decreased CO d. None of the above e. All of the above
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All of the above
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5. During emergence, when is the optimum time for a patient to be extubated? a. When protective reflexes are intact b. When the patient begins to frequently cough c. When spontaneous tidal volumes are > 150 cc d. When spontaneous movement is intact
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When protective reflexes are intact
