Anesthesia for laparoscopic and robotic surgery – Flashcards

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Laparoscopy became more popular with the advent of ______ and means of ___-______ display and ___________. These inventions reduced the complication rate.
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television on-screen magnification
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1901-________ exam of peritoneal cavity, known as ________, attempted by german surgeon ______ ______ to evaluate effects of pneumoperitoneum on intraabdominal hemorrhage. -1910 Jacobaeus used a cystoscope to examine the abdominal cavity 1975-________ first attempted organ resection via _________ (salpingectomy) 1981-________-first lap ______; revolutionary figure, called for suspension of his medical license and journal considered his work to be unethical 1988-_______&_______-first performed lap ________. required development of means of placing _____ _______. >95% of these are now performed laparoscopic
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endoscopic "celioscopy" George Kelling Tarasconi laparoscopy Semm appendectomy Reddick and Olsen cholecystectomy surgical clips
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Laparoscopy-AKA _____ ______ _______ that is performed through multiple small incisions, employing a _______ and a ___________ for visualization
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minimally invasive surgery camera pneumoperitoneum
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Equipment for laparoscopy: _______-cannulas through which cameras and ___________ are inserted into abdomen _________-now all _______, using FO ________ operated instruments are inserted via multiple small ________ (____-____cm)
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trocars instruments cameras digital Hand incisions 0.5-1.5 cm
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Pneumoperitoneum-________ of the abdominal cavity to allow ________ and surgical _______. Initial creation of this is responsible for significant proportion of complications.
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insufflation visualization manipulation
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Pros of laparoscopy: -smaller incisions and decreased ______ _______ -reduced _______ -decreased _________ -_______ length of stay in hospital -decreased risk of _________
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stress response bleeding pain shorter infection
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cons of laparoscopy: -Loss of ____ _____ ______ with hands -_____ ______ is compromised due to ___ camera -limited _______ -steep _____ ________ -multiple physiological changes that can be deleterious to patient __________
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direct organ contact depth perception 2D ROM learning curve health
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2 methods of pneumoperitoneum: -_______ _________ introduced-connected to ____ _____ ______ to allow insufflation. Pierces abdominal wall at ________ point, either _____ or ______ umbilical. -_______ ________-1-____ cm midline _______ incision at lower border of ________. insertion of initial _______ with high flow rate gas connected. (this is much more _______ with newer surgeons)
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Veress needle high flow gas thinnest infra or intra Hasson technique 2.5 vertical umbilicus trocar common
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Insufflate the cavity until ______ ______ is reached. ___-_____ mmHg pressure is most common. Rarely will increase beyond _____mmHg. Machine will automatically stop gas flow when set pressure is reached.
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pressure limit 10-15 15
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magnitude of patient response to pneumoperitoneum depends on: degree of ______, length of _______, patient ________, age, periop ______ ________, and presence of preexisting _______ or _______ disease.
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IAP (intra-abdominal pressure) surgery position volume status pulmonary cardiac
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Complications of pneumoperitoneum occur from the _____ mechanical _______ which causes stimulation of _________ responses
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direct pressure neurocirculatory
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Safest way to establish pneumoperitoneum:
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cut down with needle insertion (from review in class)
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Why is CO2 used for insufflation? -it is ________ -can be _____ by _______ and ______ by _______ system -it is non _______ and much of laparoscopic surgery will employ ________ -risk of _____ ______ is lower than with other choices
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physiological absorbed vasculature eliminated respiratory flammable cautery gas embolism
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Other gases used for pneumoperitoneum: (5)
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air N2O argon helium oxygen
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CV effects: -_______ venous return, decreased _________ -increased _______ and ______-not a reliable measure of cardiac filling pressures during pneumoperitoneum -_____ decreases secondary to decreased venous _______ -CO-usually _______; proportional to increase in ________. ___-____% decrease immediately after _________. CO can increase due to ______ _______
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decreased LVEDV RAP PAOP SV return decreased IAP 10-30 insufflation stress response
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Insufflation pressures >______mmHg collapse ______ and cause drastic ____ in venous return
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18 cava decrease
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Heart rate-______; often ______ to changes in filling or pressures
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variable compensatory
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SVR, PVR, and MAP-_______ due to mechanical and ______ _______. compression of ______ vessels and release of ________ hormones (vasopressin and renin)
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increase stress response IA neuroendocrine
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SVR ______ is attenuated by _________ _________, reverse _________ worsens the increase
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increase trendelenburg position trendelenburg
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_________-caused by increased _____ tone due to stretching of _________ and compression of ________ and most often causes __________
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arrhythmias vagal peritoneum vagus bradycardia
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The drift towards normal _____ values after initial changes seen with _______ are thought to be due to _________ changes.
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CV insufflation neurohormonal
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Elderly patients have less _______ mechanisms
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compensatory
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Increase IAP causes ______ displacement of the diaphragm, causing collapse of ______ portion of lung. this causes decreased ________ and increased ________
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cephalad dependent compliance PIP
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Pulmonary effects: -_____ arterial oxygenation -decreased _______ and ______-->worse in obese and _______ -atelectasis, _______, increased _______ ________ -increased _______ with _____ pH due to high solubility of _______ and smaller ______
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decreased FRC TLC COPD shunting airway pressures PaCO2 decreased CO2 TV
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What position attenuates all of the bad pulmonary effects of insufflation?
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reverse trendelenburg
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What positioning makes all of the bad pulmonary effects worse?
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trendelenburg
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In patient with severe _____ disease )ASA ____ or more, the rise of _______ is unreliable. ________ may not be a reliable index of _______ during __________.
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pulmonary 3 PaCO2 ETCO2 PaCO2 insufflation
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What can occur when the patient is put in steep trendelenburg positioning for surgery?
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endobronchial displacement of ETT (if patient desats:turn up O2, listen to BBS)
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What can you do besides increasing FIO2 to improve oxygenation while patient is in trendelenburg with high peak pressures?
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-put on pressure control (40 limit for pressure) -increase TV -increase RR **important to adjust before exsufflation***
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In patient with pulm disease, __________ is preferred due to decreased postop ventilatory compromise
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laparoscopy
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________ and mechanical stress of pneumoperitoneum cause increased outflow of _________ and ________ release
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hypercapnia SNS catecholamine
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increased ___________ release immediately after insufflation. ______ activity-____x increase in _____ and ________ concentrations Effect is the increase in _______ and _____
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vasopressin RAS 4 renin aldosterone SVR PV
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increased PaCO2 causes increased cerebral ______ ______ velocity. when patient is normocarbic, CBF ________. -increase ________-independent of _________ -_________ pressure increase may occur with steep head-down position (glaucoma)
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blood flow normalizes ICP PaCO2 intraocular
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What does insufflation do to renal and hepatic systems?
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-decrease RBF, GFR, UOP -release of ADH and acidosis causes vasoconstriction -changes in hepatic blood flow are controversial (vasodilating effect of CO2 is thought to attenuate increased splanchnic blood flow)
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What can cause a gas embolism?
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-direct needle placement into vessel -gas insufflation of an abdominal organ
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Incidence of gas embolism
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0-69% (highly controversial bc not all cause serious CV effects-microemboli)
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Treatment of gas embolism-
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exsufflate, flood field with saline, if CVL aspirate, listen for "mill-wheel"
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What can cause vascular injury?
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1. trocar or needle into aorta, vena cava, iliac vessels 2. inadvertent disruption of cystic or hepatic artery during lap chole 3. injury to abd wall vessels
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treatment for vascular injury:
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if hemorrhage severe, exsufflation and conversion to an open procedure to control bleeding
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what 3 types of pneumos can occur?
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pneumothorax, pneumomediastium, or pneumopericardium
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If patient begins to desat during surgery and has tracheal deviation, what is likely the problem and what is the treatment?
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tension pneumo -alert surgeon, call for help, and do needle decompression (2nd intercostal space, midclavicular line), chest tube, peep
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causes of different pneumos that can occur:
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1. embryonic defects in pleuroperitoneal hiatus 2. diaphragm defects (gas gets around aortic and esophageal hiatuses) 3. pleural tears 4. bullae rupture
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treatment for pneumomediastium or pericardium:
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-usually resolves in 24 hours -dependent on level of hemodynamic compromise
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GI injury can be due to: treatment:
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trocar or needle insertion into bowel, liver, spleen or mesentery -surgical repair
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What cardiac arrhythmia is most common? treatment?
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bradycardia -exsufflation if severe, or anti-muscarinic (glyco or atropine), or sympathomimetic (epi)
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What can cause subQ emphysema? treatment?
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incidental extraperitoneal insufflation -no treatment unless local compression compromises pt status -will absorb the gas
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What nerve injuries are a risk with trendelenberg? What about with lithotomy?
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-brachial plexus from shoulder braces -common peroneal (fibular) nerve; if prolonged can also cause compartment syndrome
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Laparoscopy can be safely performed on patients with a wide array of comorbidities. Patients at increased risk of poor outcome include: -increased ______-tumors, hydrocephalus, head trauma -______ (eyes) -________ disease-cystic fibrosis -poor ______ function-CAD, CHF, terminal valve insufficiency
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ICP glaucoma respiratory CV
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What is the recommended airway? Why?
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ETT with controlled ventilation bc it decreases CO2 and vent compromise associated with insufflation
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what airway is acceptable for pelvic laps? IAP kept <_______ can not use in patients iwth other LMA contraindications such as ______ or _________
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pelvic laps 15 mmHg obesity GERD
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NMBA must be appropriate for _______ ________. increased risk of _______ associated with reversal.
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surgical length PONV
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ASA ___+ may require invasive monitors during pneumoperitneum. ETCO2 is always a standard monitor.
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3
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intraoperatively: -increase _____ about ____% to keep patient normocarbic -liberal _____ will decrease CV effects -use of ____ is controversial
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MV 15 IVF N2O
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rule of 15:
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when using an LMA: less than 15 degree tilt, <15 mmHg IAP, <15 min duration
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nitrous can diffuse into ______, causing _______ and increases risk of _________ (all controversial)
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bowel distention PONV
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What can cause sphincter of oddi spasm? what is the treatment?
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intraop use of narcotics that interferes with intraop cholangiogram -treat with glucagon, nitroglycerine, or naloxone
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CO2 is a _______ irritant that may cause abdominal, incisional, or _______ pain that can be treated with opioids, nsaids, and injection of local at site
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diaphragmatic shoulder
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Avoid large doses of ________ to attenuate PONV. Administration of 5HT3 inhibitors closer to ______ is more effective
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narcotics extubation
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Preop with cardiac pt: -________ if EF <_____% -possible monitors: -open _______
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echo 30 art line, PA catheter, TEE, ST analysis Lap
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intraop with cardiac pt: -slow _________ -low ______ -________ augmentation prior to insufflation -drugs: -experienced surgeon
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insufflation IAP preload (give fluids if will tolerate) remifentanil, vasodilating drugs like nicardipine, nitroglycerine, inotropes
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Postop with cardiac patient: -_______ recovery -use of ______
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slow clonidine
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Cholangiography adds ___-____min to lap chole.
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30-120
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Lap appendectomy is always a ___________. If female of childbearing years:
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RSI check pregnancy test bc can present with similar symptoms with pregnancy
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-Lap nissen-always ______, CRNA responsible for insertion of large rubber ________
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RSI bougies
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with a lap __________, prepare for labile swings in BP
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adrenalectomy
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lap bowel resection: if for obstruction do __________, may use ____-______ so maximize relaxation
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RSI hand-assist
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lap inguinal hernia repair-usually in _______; adequate ________ _____ makes procedure easier
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males muscle relaxation
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lap hysterectomy-potential for ____ ____ or _______ compromise
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blood loss ureter
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lap tubal-insure _____ _______ test. usually performed ___-____ weeks post delivery--may still be an ______ risk
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negative pregnancy 4-6 aspiration
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has a highly variable procedure length--be prepared for everything
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exploratory laparoscopy
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west lung zones: 1- 2- 3-
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PA>Pa>Pv Pa>PA>pv Pa>Pv>PA
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supine patients develop _____ ______ due to vascular congestion in the _____ portions (zone __) of the lung and changes compliance. _______ ________ in obese patients
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VQ mismatch dorsal 3 aortocaval compression
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lateral patients: VQ mismatch ______ due to gravitational forces. _______ is greater in down lung and ________ is better in up lung. minimal _____ alterations unless __________
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increases perfusion ventilation CV hypovolemic
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lithotomy-abdominal contents are displaced ______ and decrease _____ and increase _______. causes decreased ________
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TV peak pressures CO
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Robotic surgery: -changes from ____ to _____ -fluid replacement-consider _____ and surgical field -_____ _______ is necessary -positioning usually ______ ______ _______ -lateral position can lead to _______
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2D 3D edema muscle paralysis steep head-down rhabdo
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