Anesthesia for GU/GYN Procedures" – Flashcards
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What % of anesthetic procedures are GU/GYN?
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10-20%
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T/F Most GU/GYN cases involve younger patients.
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false, usually the elderly with comorbidities
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Why is a cystoscopy or transurethral resection of bladder tumor (TURBT) done?
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to examine and treat lower urinary tract disease
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What structures can one visualize during a cystoscopy or transurethral resection of bladder tumor?
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anterior and posterior urethra, bladder neck, and bladder
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What are the two main symptoms one presents with necessitating a TURBT?
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hematuria and voiding disturbances
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Why is a ureteroscopy done?
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provides access to upper urinary tract and kidney for diagnostic endoscopy and biopsy, removal of renal calculi, and passage of stents
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What type of anesthesia will a ureteroscopy typically necessitate?
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general or regional
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What are the preoperative considerations with respect to cystoscopy and TURBT?
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- hematuria - recurrent UTIs - renal calculi - urinary obstruction - bladder biopsy - retrograde pyelograms - lithotripsy - placement or manipulation of uretheral stents
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Are cystoscopy long surgeries?
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no ~ 15 minutes
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EBL of cystoscopy?
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minimal- difficult to assess because of the massive amount of irrigation fluid
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What type of position will the patient typically be in for cystoscopy and TURBT?
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lithotomy
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What are the two most common nerve injuries to be aware of directly related to lithotomy positioning?
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-common peroneal nerve -saphenous nerve
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How does a common peroneal nerve injury manifest?
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- loss of dorsiflexion
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How does compression of the saphenous nerve manifest?
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- numbness along the medial calf
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What are the two physiologic alterations with lithotomy positioning?
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-decreased FRC -increased venous return (acute) *Decreased FRC predisposes patients to atelectasis and hypoxia...accenutated by trendelenburg position *Increased venous return may exacerbate CHF; conversely, lowering legs rapidly decreases venous return and can result in hypotension (vasodilation from anesthetics accentuates hypotension)
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T/F Cystoscopy are short duration surgeries and often done in outpatient settings. LMAs are appropriate, but these patients need to be VERY deep before any stimulation
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True
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What dermatomal level (regional anesthesia) is appropriate for cystoscopy and TURBT?
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T10
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What is the obterator reflex?
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Stimulation of the obturator nerve by electrocautery in the lateral bladder wall causing external rotation and adduction of the thigh
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Does regional anesthesia abolish the obturator reflex?
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No
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How can the anesthetist abolish the obturator reflex?
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- give a little bit of NMB (ie 20-50 mg of Suc)
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What is the major complication of cystoscopy and TURBT?
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bladder perforation
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How does bladder perforation manifest?
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-poor return of irrigation fluid -hemodynamic instability (tachycardia, hypertension, extended abdomen)
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What are the indications for TURP?
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- symptomatic BPH - moderate to severe urinary tract symptoms - gross hematuria - recurrent infections - renal insufficiency - bladder stones
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Why is TURP performed?
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it is the primary treatment for symptomatic BPH
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What is required during TURP surgery?
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continuous irrigation of the bladder and prostatic urethra to maintain visibility, distend operative site, and remove tissue and blood
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How can the absorption of the irrigation fluid be managed?
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Tell the OR nurse to decrease the height of the irrigation fluid to bring the pressure down.
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What are typical irrigating solutions for TURP?
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- Sorbitol 2.7%/Mannitol 0.54% - Glycine 1.5% - distilled water
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Why is Sorbitol/ Mannitol dangerous as a TURP irrigating fluid?
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- Sorbitol is metabolized to fructose and can produce hyperglycemia - Mannitol causes intravascular volume expansion and exacerbates fluid overload
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What is the danger of using distilled water as a TURP irrigant?
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- can cause massive intravascular hemolysis, hemoglobinemia and renal failure --> dilutional hyponatremia
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What is the danger with Glycine as an irrigation fluid?
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it is metabolized in the liver to ammonia and glyoxylic acid by oxidative deamination - potentially causes hyperammonemia --> depressed mental status/coma and visual disturbances
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Which patients should blood be crossmatched for with respect to TURP?
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anemic patients and those with glands > 40mL
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Transurethral approaches are only good for prostates under what size?
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80 ml = open)
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What are the most common causes of death among patients undergoing a TURP
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MI, pulmonary edema and renal failure (remember these are usually older men and 30-60% of them have CV or pulmonary disorders too)
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Long standing urethral obstruction can lead to what?
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impaired renal function
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T/F Bleeding can be difficult to control through the cystoscope.
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true
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Describe TURP syndrome.
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- Absorption of large amounts of fluids (2L or more) --> hypoosmolar and hyponatremic - Acute water intoxication or solute absorption can occur because irrigation fluid is under pressure
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How does TURP syndrome present?
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Presents intraoperatively or postoperatively as *headache*, restlessness, confusion, cyanosis, dyspnea, arrhythmia, hypotension, or seizures, circulatory fluid overload
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What is the average fluid absorption during a TURP?
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~ 20 ml/min
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How is TURP syndrome best recongnized with respect to anesthesia?
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awake patient under spinal
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What is the first symptom a patient will complain about if TURP syndrome is occurring?
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- headache and altered mentation
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How is TURP syndrome treated?
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- fluid restriction - loop diuretics - hypertonic saline - midazolam, phenytoin, diazepam, or thiopental - intubation to prevent aspiration if not already done
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If spinal or epidural is chosen for a TURP, what sensory level must be achieved?
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T10
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Your patient is taking a lot longer to wake up after a TURP than you expected. What could be a cause of this?
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Hyponatremia from TURP syndrome
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What do you expect your EBL to be in a TURP?
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3-5 ml/min
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What is the BEST way to monitor a patient for TURP syndrome?
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mental status of the AWAKE patient
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Hypothermia is a complication of TURP. Why is this and what can this cause?
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- irrigating fluids are not warmed before they are instilled into the bladder. - Hypothermia can lead to post op shivering which can dislodge clots and promote postop bleeding
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What are signs of bladder perforation in an awake patient?
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- nausea - diaphoresis - retropubic or lower abdominal pain (large perforations will present as sudden unexplained hypotension with generalized abdominal pain)
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what is an early sign of fluid overload?
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- decrease in arterial oxygenation
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What is the advantage of a laparoscopic radical prostatectomy?
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-less blood loss -shorter hospital stay -quicker return of normal patient function
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What position is typically used for a laparoscopic radial prostatectomy?
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steep trendelenburg
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What incision is used for a radical retropubic prostatectomy?
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lower, midline abdominal incision
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T/F A radical retropubic prostatectomy is often associated with little blood loss.
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false, significant blood loss - (use direct arterial pressure monitoring)
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What does a radical retropubic prostatectomy entail?
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removal of the prostate, seminal vesicles, ejaculatory ducts and part of the bladder neck
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What patient would be a good candidate for a radical prostatectomy?
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- localized prostate cancer - > 10 years life expectancy
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What patient would either opt for radiation or observation?
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prostate cancer in patients 70 years or older
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What sensory level must be achieved with a radical retropubic prostatectomy?
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T6
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What is the anticipated surgical time for a radical prostatectomy?
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1-3 hours
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What is the anticipated blood loss for a radical prostatectomy?
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500- 1000 ml
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What intraop issues should you anticipate and plan for?
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respiratory due to positioning and CV because of positioning and blood loss
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What is the common procedure for bladder cancer?
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radical cystectomy
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A radical cystecomy has a midline incision from where to where?
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pubis to xiphoid process
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What are the major concerns with the radical cystectomy?
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-significant blood loss -caution with the medications these patients may have been treated with (chemotherapy)
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What organ system suffers toxic effects with Doxorubicin?
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heart
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What organ systems suffer toxic effects with Methotrexate?
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liver, brain, and kidneys
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What organ systems suffer toxic effects with Cisplatinum?
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brain and kidneys
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What organs are removed in a male for radical cystectomy? A woman?
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Men: bladder, prostate, seminal vesicles Women: bladder, uterus, cervix, anterior vaginal vault
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Is creating a neobladder stimulating?
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no- will probably need to use pressors at this time
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T/F It is not anesthesia's job to note when the ureters are cut
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false, everything is our job
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What is the main surgery for renal cancer?
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radical nephrectomy
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Where is the incision located for a radical nephrectomy?
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- anterior, subcostal, flank, midline thoracoabdominal incision
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What is a potential complication associated with radical nephrectomy?
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extensive blood loss
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What happens when there is retraction of the IVC? What is your responsibility in this regard?
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transient arterial hypotension - must monitor DIRECT arterial pressure!
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Intraoperative considerations for a simple/ partial cystectomy, radical cystectomy or a radical cystoprostatectomy?
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- 2-6 hours - EBL - min to 1500 ml - GETA +/- epidural 2 14-16 g IV T & C 2-4 units - art line +/- CVP
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Which has more blood loss- a radical or partial nephrectomy?
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partial because in a radical the artery and vein are clamped; a partial cannot clamp the artery long
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What is a complication associated with the kidney rest?
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- decrease in venous return
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T/F Nephrectomy is usually performed after chemo
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false- renal cell cancer is not responsive to chemo and usually the radical nephrectomy is the standard approach
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How do we need to optimize blood flow to the "good" kidney?
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maintain adequate hydration
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Intraoperative considerations for a partial/ radical nephrectomy or laparoscopic nephrectomy?
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- 2-4 hours - lateral, flexed, kidney rest elevated - EBL 300 - 1200 ml - 2 14-16 g IVs - T & C 2-4 units -art line - +/- CVP - CPB? - TEE?
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What position is used for the radical nephrectomy and what are its complications
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- lateral, flexed, kidney rest elevated - stretching of the vena cava - decrease blood flow causing hemodynamic instability
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What is used to clamp the renal artery? - why is this important?
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Bull dog - we need to mark the time and tell the surgeon EVERY 5 minutes! MAX 20 minutes!
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What happens if there is an IVC thrombectomy?
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-significant bleeding -potential for thrombus to break free and enter the heart -continuous TEE monitoring
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What are the special concerns with transvaginal procedures?
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-lithotomy/ trendelenburg position -very stimulating procedures -absorption of irrigants for hysteroscopy
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What are advantages and disadvantages of laparoscopic transabdominal procedures?
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Advantages: small incisions, lower risk of wound complications, reduced post op pain, improved recovery Disadvantages: poor visualization, injury to viscera and vessels, complications to CO2 insufflation
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What are the symptoms associated with absorption of irrigants for hysteroscopy?
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-hypervolemia -hyponatremia -increased osmolarity leading to HTN, bradycardia, AMS, N/V, HA, agitation, and lethargy
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Will the signs and symptoms be recognizable for absorption of irrigants in hysteroscopy?
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Not under general anesthesia
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How is absorption of irrigants for hysteroscopy treated?
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-stopping surgery -labs, furosemide, and administration of NS
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What are the S/S of a CO2 embolism?
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-sudden and severe hypotension, arterial desaturation, and decreased ETCO2
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What is the treatment for CO2 embolism?
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-immediate D/C of insufflation -100% O2 -place in left lateral head-down position
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T/F N/V is a major concern with trans-abdominal procedures.
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true
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What are the special concerns with intra-abdominal procedures?
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-blood loss may be precipitous and unexpected -anticipate progression to more radical surgery after pathology -major fluid/electrolyte shifts, blood and heat loss, and coagulopathies
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What is the overall goal for a staging laparotomy for ovarian cancer?
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-accurate staging and optimal tumor debulking (to < 1 cm residual)
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Why does ovarian carcinoma have the highest rate of mortality of all GYN malignancies?
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- usually discovered in advanced stages with pelvic masses
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What is involved in a standard staging laparotomy for ovarian cancer?
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-meticulous exploration of abdominopelvic cavity -abdominopelvic cytology -multiple random and targeted biopsies -TAH/BSO, pelvic and paraaortic lymph node dissection, infracolic omentectomy, and appendectomy
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How long do staging laparotomy for ovarian cancer usually take? EBL?
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1-5 hours 500-1000 ml
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What are the preoperative anesthetic concerns with staging laparotomy for ovarian cancer?
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-usually diagnosed at a late stage --> significant ascites and large tumor mass -bowel resection and lymph node dissections occasionally performed at same time -respiratory, cardiac, and GI abnormalities
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What is the purpose of the pelvic extenteration?
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-Involves en bloc resection of all pelvic tissues, including uterus, cervix, vagina, bladder, and rectum -Goal is curative, with removal of all cancer tissue and reconstruction of appropriate diversions for urine and stool
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Why perform a pelvic exenterating surgery?
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it is an ultraradical surgical approach for advanced and radioresistant cervical cancer
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What three procedures are involved in pelvic exenterating?
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- radical hysterectomy - cystectomy with urinary diversion - proctocolectomy with permanent colostomy
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What three techniques are typically used for vaginal reconstruction?
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- omental pelvic sling - gracilis myocutaneous flap - rectus abdominal muscle flap
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How long are pelvic exenteration?
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8 to 12 to 15 hours....
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What is the most common GYN malignancy in the US?
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endometrial cancer
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Next to the supine position, what is the most common position utilized for urological and gynecological procedures?
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lithotomy
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What physiologic issues are associated with lithotomy positioning?
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-decreased FRC -increased MAP but cardiac output not changed significantly -rapid lowering of legs decreases venous return causing hypotension
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Because of the short duration (15-20 min) and outpatient setting of most cystoscopies, what type of anesthesia is typically chosen?
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general anesthesia with LMA
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Both epidural and spinal blockade with a _____ level provide excellent anesthesia for cystoscopy.
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T10
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Manifestations of TURP (transurethral resection of the prostate) syndrome are primarily...
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-circulatory fluid overload -water intoxication -toxicity from the solute in the irrigating fluid
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Absorption of TURP irrigation fluid is dependent on...
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the duration of the resection and the pressure of the irrigation fluid
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When compared with general anesthesia, regional anesthesia for TURP may...
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reduce the incidence of postoperative venous thrombosis. It is also less likely to mask symptoms and signs of TURP syndrome or bladder perforation.
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Patients who are undergoing retroperitoneal lymph node dissection and who have received bleomycin preoperatively are at increased risk for...
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developing postoperative pulmonary insufficiency; These patients may be particularly at risk for oxygen toxicity and fluid overload, and for developing acute respiratory distress syndrome postoperatively.
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Patients with a history of cardiac arrhythmias and those with a pacemaker or internal cardiac defibrillator (ICD) may be at risk for...
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developing arrhythmias induced by shock waves during extracorporeal shock wave lithotripsy (ESWL). Shock waves can damage the internal components of pacemaker and ICD devices.
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Urological procedures account for _______% of most anesthetic practices.
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10-20
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What is the most common urological procedure?
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cystoscopy
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Indications for cystoscopy include all of the following S/S...
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hematuria, recurrent urinary infections, renal calculi, and urinary obstruction
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Because of their short urethra, what can be an anesthetic choice in women for diagnostic studies?
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Viscous lidocaine topical anesthesia with or without sedation
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The most common surgical complications of TURP are...
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clot retention, failure to void, uncontrolled hematuria requiring surgical revision, urinary tract infection, and chronic hematuria
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Why can TURP syndrome occur?
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Transurethral prostatic resection often opens the extensive network of venous sinuses in the prostate, potentially allowing systemic absorption of the irrigating fluid
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How does TURP syndrome occur intraoperatively or postoperatively?
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headache, restlessness, confusion, cyanosis, dyspnea, arrhythmias, hypotension, or seizures, and it can be rapidly fatal.
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How can TURP syndrome be treated?
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Most patients can be managed with fluid restriction and intravenous administration of furosemide.
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If there is symptomatic hyponatremia or seizures, how should this be treated?
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Symptomatic hyponatremia resulting in seizures or coma should be treated with hypertonic saline. Seizure activity can be terminated with small doses of midazolam (2-4 mg). Phenytoin, 10-20 mg/kg intravenously (no faster than 50 mg/min), should also be considered to provide more sustained anticonvulsant activity.
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T/F Irrigating solutions should be warmed to body temperature prior to use to prevent hypothermia.
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true
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When should bladder perforation be suspected?
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in settings of sudden hypotension or hypertension, particularly with acute, vagally mediated bradycardia
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Cystoscopy provides visualization of what structures?
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anterior and posterior urethra, bladder neck, and bladder
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Positioning for cystoscopy?
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lithotomy
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Common injury with lithotomy position?
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common peroneal nerve injury (leg leaning on the candy canes without padding)
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If pursuing a regional technique for a cystoscopy, what level should the block be at?
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T10 (umbilicus)
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What is the obturator reflex?
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externa rotation and adduction of thigh secondary to stimulation of obturator nerve by electrocautery current through the lateral bladder wall.
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T/F The obturator reflex can be blocked by regional anesthesia
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false, only reliably blocked with NMB under general
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By monitoring the return of irrigation fluid, what can we detect?
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perforation of the bladder (returning less irrigant that infused would imply perforation)
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What is the most common benign tumor in men? how is it treated?
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BPH..treated with TURP
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Irrigating solutions are using during TURPs...what is a possible adverse event if the solution contains mannitol? what population might this be seen more in?
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absorption of mannitol would cause volume expansion and fluid overload. this can be devastating in heart failure patients.
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Distilled water used to be used as an irrigant for TURPs, why did they stop using it?
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absorbed into circulation and caused hemolysis, hemoobinemia and renal failure. also, dilutional hyponatremia.
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Blood should be available and cross matched for prostate glands greater than what size?
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40 ml
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How does TURP syndrome present? etiology?
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headache, restless, confused, dyspnea, hypotension, seizures. Occurs due to absorption of large amounts of fluids (2 L or more) which leads to severe hyponatremia.
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On average, how much irrigating fluid is absorbed during a TURP?
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20 ml/min
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How do you treat TURP syndrome?
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restrict fluids, loop diuretics, hypertonic saline (slowly)
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Your patient has undergone a TURP. You used general anesthesia and are attempting to emerge your patient but it is extremely delayed. What is a possibility for this that is unique to TURPs?
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The hyponatremia that can occur from TURP syndrome may cause neurological changes that delay emergence.
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Anesthetic concern for radical retropubic prostatectomy?
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Associated with significant blood loss. Consider arterial line.
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Neuraxial level for prostatectomy?
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T6
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Those with bladder cancer may have been treated with chemotherapeutic agents, what medications are of greatest concern? why?
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doxorubicin- cardiac methotrexate- hepatic, neuro, renal cisplatinum- (cis/piss) renal and neuro
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T/F Both cystectomy and prostatectomy have a high estimated blood loss.
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True
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Major anesthetic concern specific for radical nephrectomy?
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Adequate hydration to optimize blood flow to remaining kidney. Also, don't forget the kidney rest!
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Patients undergoing nephrectomy may have thrombus involvment where?
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inferior vena cava
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If a patient also has an IVC thrombus, what monitoring device should be added?
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Continuous TEE monitoring because of the potential for the thrombus to break free
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Name procedures that can be performed transvaginally.
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dilation and curettage. dilation and evacuation, hysteroscopy
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Name gyn procedures that can be performed intraabdominally?
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myomectomy, ruptured ectopic pregnancy, cystectomy
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Special concern for transvaginal procedures?
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lithotomy used and instruments are extremely stimulating (assess depth of anesthesia prior to start)
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If you attempt to correct hyponatremia too quickly, what can happen? what is too fast?
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central pontine myelinolysis can occur. Corect with 3% NaCl no faster than 1-2 meq/L/h
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Ovarian cancer is usually discovered in advanced stages with what signs and symptoms?
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pelvic mass, omental caking (wtf), and ascites
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What is a procedure used for advanced and radioresistant cervical cancer?
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pevic extenteration (resection of all pelvic tissues, including uterus, cervix, vagina, bladder, and rectum), also described as ultraradical.
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Most common gyn malignancy in US?
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endometrial cancer
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A patient is having an ex-lap, hysterectomy for uterine cancer, how might this have presented pre-op when she received her diagnosis.
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Vaginal bleeding in a postmenopausal woman
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T/F Endometrial cancer may be treated with radiation prior to surgery.
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true
