GYN Flashcards

Question

Hysterectomy: Vaginal, Abdominal, Laparoscopic or Robotic Description

Answer 1

Surgical procedure to remove the uterus +/- BSO Many various approaches

Answer 2

Uterine myoma, pelvic organ prolapse, pelvic pain due to endometriosis/adhesions, uncontrolled uterine bleeding, dysmenorrhea, endometrial hyperplasia, gynecologic cancers, pelvic masses

Answer 3

Supine = abdominal; lithotomy = vaginal; lithotomy/TB = lap/robotic Antibiotics 1-2 hours EBL > 200-300 mL = open; 100-200 mL = vaginal Painful > multimodal analgesia

Answer 4

Directed by H & P Comorbidities > stress urinary incontinence; obesity Hgb/Hct > T&S/T&C Administer midazolam 1-2 mg IV Consider acetaminophen 1000 mg PO, gabapentin 300-600 mg PO, celecoxib 200 mg PO Consider PONV prophylaxis (aprepitant 40 mg PO)

Answer 5

Neuraxial appropriate for open abdominal/vaginal > T4/T6 level Standard induction Standard monitors > +/- arterial line/CVP per patient Standard maintenance > MR PONV prophylaxis Multimodal analgesia > ketamine 0.5 mg/kg bolus + 5 mcg/kg/min infusion IV x 1-2 Goal-directed fluid therapy > warm fluids Foley catheter Check and pad pressure points

Answer 6

Vagal stimulation with cervical/peritoneal stimulation, epi/vasopressin injection, blood loss

Answer 7

PONV VTE Anemia Pain > multimodal pain management Monitor Hgb/Hct

Answer 8

Resection of all pelvic tissues including uterus, cervix, vagina, bladder and rectum

Answer 9

Advanced and radioresistant cervical cancer; occasionally advanced vaginal and vulvar carcinoma

Answer 10

Lithotomy NGT VTE prevention (SCD/heparin) Antibiotics 8-12 hours EBL = 1200-1400 mL ICU postop Painful > multimodal analgesia > opioids/non-opioids, epidural, TAP, PCA Risk of PONV

Answer 11

Use PEEP Monitor ABGs intraop Large IV x 2 > potential for large blood loss Strict fluid maintenance > warm fluids Maintain UO 0.5-1 mL/kg/hr T&C Standard monitors > + arterial line and CVP Foley catheter Check and pad pressure points Check eyes SCD

Answer 12

Hypothermia, VTE, coagulopathy, trauma to kidney/ureters (watch for reduced UO and hematuria), bleeding (monitor Hgb and coagulation), metabolic acidosis, peripheral nerve injury, fluid overload

Answer 13

Reinforcement of the cervix to prevent premature cervical dilation in patients with incompetent cervix Emergent or elective Lithotomy (LUD if pregnant) Duration 30 min-1 hr EBL = 25-50 mL (minimal) Preop directed by H & P; obtain H & H; reduce risk of aspiration, administer midazolam Regional or general Standard induction, maintenance and monitors (fetal monitor if pregnant)

Answer 14

Complications: Preterm labor, hypotension, peroneal nerve injury Multimodal pain management PONV prophylaxis

Answer 15

Assess for respiratory status > no significant respiratory disease = tolerate insufflation well; pulmonary disease = respiratory compromise from increased intraabdominal pressure secondary to CO2 Assess for cardiovascular status > no significant cardiovascular disease = tolerate insufflation well; cardiovascular disease = increased SVR and decreased venous return secondary to CO2; increased PaCO2 = increased risk of dysrhythmias Assess GI status > assess NPO status if ER; assess bowel prep; BMI complicates steep TB; high intra-abdominal pressure + TB = increased aspiration risk Administer midazolam 1-2 mg IV Multimodal/preemptive analgesia > acetaminophen 1000 mg PO, gabapentin 300 mg PO PONV prophylaxis > aprepitant 40 mg PO

Answer 16

RSI w ectopic pregnancy OGT/NGT Multimodal analgesia > opioid sparing, non-opioids, epidural, PNB, PCA, ketamine (0.5 mg/kg bolus +/- 5 mcg/kg/min) Maintain normothermia Euvolemia with balanced salt solution PONV prophylaxis Foley MR EBL minimal

Answer 17

Abdominal access injures, pneumoperitoneum effects (SQ emphysema, pneumothorax, shoulder pain (diaphragmatic irritation), CO2 retention, air embolism, increased HR, MAP, PVR and SVR, decreased VC, venous return, preload and CO), brady-dysrhythmias (vagal stimulation; reduce/halt pneumoperitoneum; Robiul/Atropine), nerve injury (long duration), hypothermia, neuropathy, fluid overload

Answer 18

PONV VTE Hypothermia Pain

Answer 19

Use of instrumentation to examine the urinary tract dx or therapeutic procedures

Answer 20

lithotomy standard monitors multple anes. techniques duration: short to several hours

Answer 21

SHort acting spinal - concern for TNS with lidocaine GA recommended for procedures near the obturator nerve (ON block) LMA - often used for brief outpatient urologic RA desired for at risk autonomic hyperreflexia (Block transmission of afferent impulses and prevent uncontrolled reflex vasoconstriction

Answer 22

dx, staging, tx of non invasive bladder cancer Tx BPH Resectoscope is inserted through urethra to access the bladder and the tumor is resected using electrocautery or laser. ALso obstructing median and lateral lobes of prostate tissue bleeding controlled by coagulation current

Answer 23

Obturator nerve --> cautery resectoscope stimulation may result in adduction of the legs --> consider GA with MR

Answer 24

continuous irrigation by washing away blood and dissected prostatic tissue ideal solution: transparent, isotonic, nontoxic

Answer 25

Cytal (sorbitol/mannitol) and glycine = MOST common NS or LR highly ionized and promote dispersion of high current from resectoscope --> newer techniques of TURP (bipolar and laser) prevent electrical dispersion and minimize irrigant absorption Distilled water = hemolysis of RBC due to hypotonic composition but less optical composition

Answer 26

More acceptable with new bipolar and laser techniques due to reduced risk of irrigation absorption and TURP syndrome

Answer 27

Comfort pelvic relaxation monitor s/s of excessive fluid absorption and bladder or prostate capsule perforation.

Answer 28

T10 to avoid sensation resulting from bladder distension from the irrigation fluid >T9 avoided

Answer 29

blood loss postop venous thrombosis

Answer 30

Serious neurologic and CV sequelae resulting from significant absorption of hypo-osmolar electrolyte-free irrigation fluids due to water intoxication, fluid overload, and hyponatremia

Answer 31

shortly after resection begins up to first day postop

Answer 32

Hypertension (late hypotension) Bradycardia Arrhythmia PE hypoxemia CHF confusion restlessness seizures coma Visual/transient blindness N/V HA Hyperkalemia bronchospasm bleeding

Answer 33

supportive care - oxygenation, ventilation, circulation seizures - anticonvulsants fluid restriction/diuretic therapy w furosemide treat hypoosmolarity/ natremia slowly

Answer 34

Central pontine myelinolysis

Answer 35

3% sodium chloride 100ml/h until serum sodium concentration is greater than 120 mEq/L No faster

Answer 36

Prostatic venous sinuses open --> direct intravascular absorption of irrigation solution occurs hydrostatic driving pressure of the irrigating fluid compounds the problem

Answer 37

10-30mL/min of resection time 6-8L can be absorbed in 2 hours 1L into the circulation in 1 Hr can decrease serum sodium 5-8 mEq/L

Answer 38

Limit to 1 hour

Answer 39

<120 CNS <115 - ECG/changes <110 VT/VF

Answer 40

Volume overload with PE Dilutional hyponatremia Hypoosmolality Cardiac defects Renal toxic effects (glycine) Hyperglycemia

Answer 41

Irrigating solution that contain glucose or sorbitol (which is metabolized to fructose) can lead to hyperglycemia nd possibly lactic acidosis in diabetic patients

Answer 42

Visual disturbances reported after TURP include halos, loss of light perception, and transient blindness > may occur during or several hours after the resection and usually resolve within a few hours > pupils are often dilated and unresponsive

Answer 43

Glycine is a nonessential amino acid that serves as an inhibitory neurotransmitter within the central nervous system

Answer 44

Glycine can become oxidized into ammonia - leading to additional CNS toxicity

Answer 45

suppress release of norepi and dopamine in CNS causing encephalopathy

Answer 46

The first postop hour with symptoms of N/V quickly leading to coma

Answer 47

Hyperammonemia for at least 12 hours postop

Answer 48

Hypertrophied prostate contains extensive plexus of venous sinuses which are opened during TURP May be tamponaded by a foley catheter

Answer 49

Prostate size, vascularity, degree of inflammation, duration of surgery, and use of adrenergic agonists

Answer 50

Urokinase and plasminogen activator from mucosa causing local fibrinolysis and bleeding from resected suraces

Answer 51

DIC leading to systemic coagulopathy

Answer 52

aminocaproic acid

Answer 53

Due to difficult instrumentation bladder overdistension hydrogen gas explosion accidental stimulation of obturator nerve during electrocautery can lead to sudden lower extremity movement, increasing risk of perforation RA will not stop this reflex

Answer 54

Suprapubic periumbilical inguinal pain while intraperitoneal rupture typically cuases upper abdominal or referred pain from the diaphragm to the shoulder or precordium.

Answer 55

Bladder perforation

Answer 56

Hypotension restlessness hiccups nausea diaphoresis

Answer 57

Suprapubic cystostomy

Answer 58

Several liters of irrigation solution - stored at room temp, and lose significant amount of body heat from absorption of cold fluid Decreased body temp is directly related to duration of sx and temp of irrigant (1c per hour)

Answer 59

Patients carry high risk of developing transient postop bacteremia and septicemia prostate contains lots of bacteria which enter circulat through open venous sinuses most cases are asymptomatic and easily treated with abx

Answer 60

Sterilize the urine, but still recommended to prevent sepsis

Answer 61

What is the irrigation fluid? What is the bag height over prostate? What is the size of the prostate? What is the expected duration of procedure? What is the operating position?

Answer 62

Assess mental status in RA GA - measure serum Na, monitoring of overload

Answer 63

Based on symptoms asymptomatic - slowly symptomatic - agressive

Answer 64

HA irritability confusion N/V are EARLY WARNING SIGNS of TURP syndrome

Answer 65

Prolonged postoperative analgesia may be beneficial after TURP because patients often complain of pain from detrusor muscle spasm (bladder muscle squeezing)

Answer 66

Renal calculi

Answer 67

calcium struvite uric acid cysteine

Answer 68

medical management first

Answer 69

likely sx interventions

Answer 70

renal colic --> acute, incapacitating pan due to dilation, stretch and spasms by complete urethral obstruction

Answer 71

ipsilateral deep flank pain without radiation

Answer 72

severe colicky pain in flank and lower abdomen nausea

Answer 73

voiding difficulties frequent and painful urination suprapubic pain

Answer 74

perinephric hematomas, kidney infections, urinary obstruction, stomach or intestinal ulcerations, post-procedural kidney impairement

Answer 75

High frequency ultrasonic, pneumatic shock or lasers to break down stone non-invasive tx for stones in proximal or mid ureter

Answer 76

Pregnancy untreated bleeding disorders abdominally placed PM's UTI

Answer 77

Pectoral placed PM internal defib AAA ortho prosthesis obesity

Answer 78

Diaphragmatic excursion can be significant in patients with a normal body weight narcs can be give to reduce this excursion there is an upper limit to this effect as set by the patient's depressed respiration

Answer 79

SLow rate breathing with high TV large shift in movement can take operative view out of focus and called the dipahragmatic excursion deep breathing can also move the stone sponaeously distal or proximal to starting location

Answer 80

Epidural cath --> loss of resistance to air technique should be minimized, the change in acoustic impedance due to air bubble can cause harmful redirection of energy to spinal comumn from kidney stone Spinal provides a quick, dense block but can be affiliated with significant hypotension that is further exaggerated in an immersed state

Answer 81

RSI those who are nauseas monitor for hypothermia LMA or ETT

Answer 82

New teq in which stones are broken under visualization laser transmitted through fiber optic wire and exitws at tip energy is released over short distance Only works for stones that can be visualized Radiographic imaging used to locate stone

Answer 83

isotonic solution and short duration reduces risk of volume overload

Answer 84

MR, for same reasons as seen in ESWL GA in supine

Answer 85

Special goggles fluid overload lithotomy position --> adequate ventilation is primary concern

Answer 86

Semirigid and flexible device to remove stones indicated for stones in distal ureter 25mm or smaller GA and postop admit removed under CT

Answer 87

PERCUTANEOUS nephrolithotomy

Answer 88

prone supine

Answer 89

Pain fever UTI renal colic septicemia bleeding pelvic/ureteral tear pneumothorax hemothorax anaphylaxis

Answer 90

retroperitoneal --> CO2 in this space communicates with thorax and SQ tissue leading to risk of subcut emphysema into head and neck --> submucosal swell and airway compromise

Answer 91

Increase intrathoracic/abdominal pressure

Answer 92

Hemodynamic alterations --> decreased CO and increased SVR

Answer 93

Renal cortical vasoconstriction

Answer 94

Steep/lithotomy cuff leak prior to ex Dexamethasone -->decreases swelling buscopan in recovery to reduce bladder spasm NO MOVEMENT sit patient up before extubation

Answer 95

Sx to remove all or part of kidney indicated for benign tumors, malignant disease, organ donation laparoscopic, robotic or open simple, partial, radical

Answer 96

Jack Knife/lateral position with raised kidney rest vena cava compression --> decreased venous return and BP, decreased resp compliance, increased Peak airway pressures, atelectasis on dependent lung

Answer 97

large blood loss, hypotension pneumothorax chronic pain PE DVT Brachial plexus painful

Answer 98

Sx to remove all or part of the prostate gland prostate cancer most common cancer in men Lap/daVince robot steep tren 45 degrees for sx exposure, supine

Answer 99

Entire prostate both seminal vesicales pelvic nodes

Answer 100

1000mL can be done general, regional, combination

Answer 101

Immediately - 1L blood to central compartment increased filling pressures, CVP, PCWP, MAP increased airway pressures, decreased lung expansion decreased renal artery blood flow venous congestion, swelling of eyes and face nerve injury

Answer 102

Sx to remove all or part of the bladder standard for muscle invasive bladder cancer

Answer 103

4-6 hours monitor urine closely until urinary path interrupted arterial line needed CVP - patient dependent blood loss - 1500mL urinary diversion

Answer 104

Radical cystectomy

Answer 105

For end state renal disease kideny donors may be living or deceased (higher success rate for living) lap sx has increased live donors --> decreased pain and scarring

Answer 106

HD patients will usually know their dry weight, which can be used preoperatively to estimate volume status important to remember that pts may be hypovolemic following dialysis

Answer 107

Met acidosis, hypocalcemia, hyperkalemia may require preop correction with dialysis coag status requires assessment of PTT, PT, fibrinogen, and platelet count due to the concern for potential uremic platelet dysfunction Evaluation of hgb levels is necessary because most pt's will be anemic prior to their transplant

Answer 108

ECG/Echo minimal required workup for EVERY patient Dobutamine stress echo should replace regular echo and be repeated every year for all the following - DM - Two of the following RF: HTN, Obese, Fam Hx of CAD, hyperlipidemia, and smoking) - any previous CAD and/or s/s

Answer 109

Rad art line CVP (10-15) induction - RSI During vascular anastomoses = aggressive fluid consider colloid Blood products as needed desmopressin 0.3mcg/kg over 30 mins for bleeding due to uremic platelet dysfunction foley OGT ABG/lytes/Hgb 1-2 hrs

Answer 110

Fentanyl Cisatracurium (Drug of choice) rocuronium

Answer 111

Hyperkalemia contraindicated

Answer 112

External iliac vein clamped first and the renal vein to iliac vein anastomosis is performed external iliac artery renal artery anastomosis is then performe dand the clamps are released

Answer 113

Furosemide mannitol to achieve diuresis

Answer 114

Drop in BP should prompt aggressive admin of fluids and or decrease VA concentration

Answer 115

hyperkalemia

Answer 116

>1ml/kg/hr or administer low dose dopamine lasix/mannitol

Answer 117

Foley clamped with abx irrigation used to fill the bladder --> unclamped after ureter reimplanted

Answer 118

UO monitored closely postop dialysis

GYN Flashcards

(153 cards)