True or False

The increased pain sensitivity in menopause does not correct even with hormone therapy

Describe what estradiol does to the following

____  # of opioid receptors

______ response to opioids

______ levels of beta-endorphins in brain, pancreas, and liver

Estradiol....

increases # of opioid receptors

decreases response to opioids

decreases levels of beta-endorphins

in brain, pancreas, and liver

Serum, radioimmunoassary: 24-72 hours post conception

Urine, antibody agglutination: 10-12 days post conception

Normal non-pregnant: 5% of CO = 50-100 mL/min

3rd trimester: 10-12% of CO = 600-700 mL/min

1. Dysfunctional bleeding
2. Diagnosis of potential cancers
3. Evacuate uterus (incomplete abortion)

Exocervix - Relatively insensitive: low density pain sensing nerves that may require IV sedation

Endocervix - Dilation of endocervix is very painful, requires analgesia

No you do NOT wait. The uterus only stops bleeding by contracting...get whatever is holding it open out of there!

If patient pale, but young/healthy, take to OR.

A missed AB is more painful, if the cervix is already partially open, it is less painful to dilate. 

A missed AB has not started dilating yet, thus it will be more painful.

What occurs at

8 weeks of pregancy?

12 weeks?

20 weeks?

8 weeks - CO changes, ETCO2, could use an LMA/IV sedation

12 weeks - Aspiration risk, needs ETT, must go to sleep

20 weeks - PIH, aortocaval compression

PGEs cause bronchodilation, decrease in SVR, and an increase BP secondary to increased CO.

PGEs can cause N/V, fever, and diarrhea.

Use ISOTONIC solution with oxytocin. 

Oxytocin is associated with TACHYCARDIA and hypotension.

Ergot typically causes Increased BP and increases PA pressures. 

It's contraindicated in unstable heart DZ and PIH.

Treat with an alpha blocker, which blocks/relaxes the vessels, not the heart.

Use hydralazine, NTG, NTP.

Labetalol has alpha/beta effects.

Clonidine and phenoxybenzamine can be used as well (not first line).

It's diagnosed by a rapid increase in beta HCG, way more than the placenta needs.

Hormonal changes outpace a normal pregnancy, patient is hormonally further along in pregnancy than weeks stated.

Hyperemesis = dehydration

PIH, anemia

Thyrotoxicosis - HTN, sweating, increased ETCO2, tachycardia, widened pulse pressure

ETT and RSI.

Use propofol or etomidate.

A sugar solution/hyponatremic, does not conduct electricty. Usually glycine or dextran

Keep track of fluid absorption.

What should you do at the following levels of fluid absorption in hysteroscopy?

1000 mL

1500 mL

2000 mL

1000 mL - Continue operation

1500 mL - End operation ASAP

2000 mL - Stop operation

A tubal occlusion is a sterilizing, irreversible procedure.

A coil is inserted into the tube which causes tissue irritation, in a few weeks, nothing will pass through the tubes.

No incisions, not a lot of fluid, fast and easy.

What wavelengths are the

CO2

Nd Yag

Dye

KTP diode

Argon

lasers used at and what eyewear color do you need?

CO2 = 10600 = Vaporize tissue = Clear

Nd Yag = 1064 = Deep tissue, TURP, stones = Clear

Dye = 580s = Skin pigment, tattoes = Blue

KTP diode = 532 = Coag/ablation = Orange

Argon = 514 = coagulation = Orange

Condylomas require you to wear a SPECIAL mask. When condylomas are vaporized, they become a live fungal spore. Vacuum is used to collect spores. 

CO2 laser is used for condylomas. 

Argon is used for liver lacerations.

Wavelengths 400-1400 can damage retinas.

True or false

Blood is is typically underestimated in hysterectomies.

What does chemotherapy do?

What is bleomycin and why don't we like it?

Chemotherapy disrupts hematopoiesis, causes resistance to infection, myocardial, renal and hepatic function

Bleomycin can cause impressive pumonary fibrosis that can be worsened with high O2 concentrations.

Saturation will still be 100% if patient is anemic (down to Hb of 5). They saturate easier because they have no competition for those sites.

Color, pulse ox, ABG, PaO2 and SvO2

True or false

Cancers can only cause a hyper-coagulable state.

False

Cancers can cause either a hyper-coagulable or hypo-coagulable state.

Common peroneal nerve (post), femoral, obturator, lateral femoral are prone to stretch.

Lower limb compartment syndrome due to limbs not positioned correctly.

Masked hypovolemia

Intravascualrly dry but missing s/sx because the legs are up, get a BP after the legs come down.

Candy canes are better (weight is on the foot)

Increased intrabdominal pressure.

6-8 weeks after pregnancy (cardiac/resp function are restored)

If they're postpartum, treat them like they're pregnant.

Anxiety

Full bladder for US means recent clear liquids (probably not NPO)

Nothing we use is technically a teratogenic. Don't use Nitrous.

Fertility cases are good for TIVA.

True or false

Preop care is the same in the clinic as it is in the hospital.

If baby is pre-mature infant (<60 weeks post conceptual age), they have a high incidence of post-op resp. failure.

If family hx of SIDs, baby needs to stay overnight for monitoring.

1. UNSTABLE ASA 3 and 4
2. CHF
3. Active substance abuse
4. Poorly controlled SZ
5. Uncontrolled DM (A1C >8.6)
6. Uncontrolled OSA
7. Sepsis/infectious DZ
8. Pain uncontrolled with PO meds

A/Ox3, stable VS for 1 hour.

Ability to ambulate unassisted

Ability to tolerate oral fluids.

Absence of significant pain/bleeding.

Do not Drive. Do not adopt or sell any stocks within 24-72 hours.

No life change decisions within 24-48 hours.

Yes, treat them as a full stomach because their motility is slow.

You don't want to be be bagging, giving NMBs, and then they aspirate.

Main concern: Dehydration

Be cautious with propofol to prevent CV instability.

What nerves supply the

1. Parasympathetic

2. Sympathetic

1. Parasympathetic - Vagus nerve

2. Sympathetic - T2-T6

1. Pregnancy (progesterone)

2. Hiatal hernia

3. Obesity

1. Laryngospasm (opens the false vocal cords)
2. Cough
3. Expiration reflex (during expiration, true vocal cords close, but false is open, glottis is open)
4. Spasmodic panting - rapid breathing 40-60 breaths/min
5. Spasmodic

1. Minimize intake (NPO)
2. Increase gastric emptying
3. Decrease gastric volume/acidity

1. H2 blockers

2. PPIs

What are the NPO requirements for

1. Clear Liquids
2. Breast milk
3. Infant formula
4. Light solid meal
5. Heavy, fatty meal

1. Clear liquids - 2 hours
2. Breast milk - 4 hours
3. Infant formula - 6 hours
4. Light solid meal - 6 hours
5. Heavy, fatty meal - 8 hours

1. Metoclopramide
2. Smoking
3. Neostygmine (increased gastric emptying but blocked by atropine)
4. Propranolol
5. Na Bicarb

1. Pain
2. Laparotomy
3. Narcotics
4. Trauma
5. Pregnancy
6. Alcohol
7. MI

1. Obese
2. Pregnancy
3. Bedridden
4. Shock
5. Trauma
6. Recent laparotomy (24 hours)
7. Chemical interference

Reglan

Onset: 1-3 min

Duration: 30-60 min

1. Cimetidine (tagamet)
2. Famotidine (pepcid)
3. Ranitidine (zantac)

1. Omeprazole
2. Lansoprazole

Vomiting >60 cmH20

Fasciculations 40 cmH20

Fasting 18 cmH20

1. Cricoid or tracheal injury
2. Unstable C-spine (trauma, do awake fiberoptic)
3. Active vomiting

Partial airway obstruction (most common)

Airway obstruction (most common)

Fracture of cricoid ring (rare)

Esophageal rupture (rare)

Backward

Upward

Rightward

Pressure

What are 3 things to consider when working with small bowel/colon cases?

What do these 3 things lead to?

1. Bowel prep = Hypovolemia
2. Hypokalemia
3. Peritonitis

These suppress intestinal activity x48 hours.

Innervated vagus (PSNS) = ↑ motility

Innervated T_6-10 (SNS) = ↓ motility

1. Gastric
2. Small Intestine
3. Large intestine
4. Pancreatic
5. Splenic
6. Hepatic

1. Celiac artery
2. Superior mesenteric artery
3. Inferior mesenteric artery

Alpha - Vasoconstriction of splanchnic circulation

Beta 2 - Vasodilation of splanchnic circulation

Vagus nerve - ↑ metabolism → ↑ blood flow to organs of the body

↑ splanchnic vascular resistance

1. Stress
2. ↑catecholamines
3. Vasopressin
4. ANG 2

1. Able to increase MAC with a lower amount of VA (2nd gas effect)
2. Patient with hypotension

1. Do you snore? Ask S/O.

2. Obesity

3. How many pillows do you sleep with at night? >2 = sleep apnea.

Food bolus cases are considered full stomachs.

Have RSI ready - SUX, Lido, Prop, ETT.

Which cases require LMAs or ETTs?

Incisional

Umbilical

Inguinal

Incisional - ETT

Umbilical - LMA

Inguinal - LMA

With an inguinal hernia, if manipulating open or laparoscopic, HR will go down.

ALWAYS pretreat with robinul (0.2mg-0.4mg)

With insufflation of CO₂, HR and BP both go down.  

Women tend to have bradycardia during laparoscopic cases.

1. Propofol when patient already breathing on their own.
2. Lidocaine, but problem is you have to give it WAY early before you wake them up, if you don't delays emergence.
3. Narcotics (fentanyl) at the end when breathing on their own and gas is usually 1/2 MAC. Let them breathe 8-12 min with ETCO2 40s-40s.

Maintain patients with 1.5 MAC and fentanyl.

Titrate fentanyl to keep RR ~12

Don't give 50 mcg all at once, give 25 mcg, then additional 25 mcg after 1st NIBP.

1. Perioperative hypokalemia → pt not eating or may have an NG tube in place
2. Pernicious anemia (B12)
3. Large 3rd space blood loss
4. Malnutrition

What are 2 s/sx of gastrectomy patients?

How should you play on inducing them?

Gastrectomy patients are TACHYCARDIC and HYPOTENSIVE although O2 sats are OK.

Propidate is a good combo. Give 2 cc of Prop and 2 cc of Etomidate, wait for effect, repeat PRN.

1. Assess pre-existing conditions and volume status
2. Pre-op beta blockers for elderly (esmolol/labetalol during induction)
3. Aspiration prophylaxis
4. Correct anemia
5. Consider TPN

• Remind RR nurses to get a BS

RSI if full stomach, if pt has NGT, then RSI.

Consider A-line/CVP

Foley 30 ml/hr

Atelectasis and pneumonia 2ndary to incisional wound.

Ask for infiltrations and give own pain meds intra-op and before leaving OR.

JP drains predisposes pt to infection.

It is our responsibility to make sure JP drawn is STILL with pt when he gets to RR.

1. Direct laryngoscopy

2. Drop the cuff and ventilate...if you hear air, edema has decreased.

3. If spontaneous RR, listen...if pt was difficult airway and multiple attempts, give decadron to reduce inflammation/swelling.

1. Smokers

2. >65

3. Obesity

1. Anxiolytics

2. Positioning complications

3. Field avoidance (operating field may be near airway)

1. Thoracic nerve injuries

2. Optimal operating conditions

3. N/V prophylaxsis, ABX,

Give decadron @ beginning and zofran @ the end

4. D/C anticoagulants

Breast biopsy - LMA OK, wait for results, may need to switch for ETT if radical mastectomy indicated.

Radical mastectomy - ETT Always!

1. Blood filtering

2. Immune processing - IgM

3. Platelet storage

1. Thrombocytopenic purpura

2. Sickle cell dz

3. Splenic trauma

4. Hodgkin disease

1. RSI!!

2. Consider H&H (may be diluted 2ndary to fluid boluses and active bleeding. Make sure blood is available in the OR before pt is in room)

3. Hemodynamic instability (have crystalloids available)

1. Major blood loss

2. Trauma of pancreatic tail and stomach

1. Gastric decompression (ask surgeon for OGT/NGT)

2. Stress steroids (hydrocortisone 100 mg IV for stress of surgery)

3. Treat infection

4. Correct abnormal blood coagulation

1. Bleeding

2. Bronchopneumonia (from atelectasis due to incisional pain)

3. Thrombotic complications

4. Atelectasis

1. Pneumococcal vaccine 1 month prior to surgery (vaccine not necessary in emergent cases)

2. Hematologic assessment

3. Blood readily available

1. Prevent dehydration (IV during NPO)

2. Warm the room

3. Have blood ready if needed

1. Standard ASA monitors

2. Continue hydration (1.5X maintenace)

3. O2 sat >95% (FiO2 50-100%)

4. Pain control

5. Maintain normothermia

6. Transfuse if necessary (avoid Hgb >11)

Average lifetime risk of 6% for colorectal Ca.

Crohn's dz is most common cause, cancer is 2nd most common cause for bowel resections.

1. Decreased intravascular fluid (↓ K)

2. Bowel obstruction

3. Contamination

4. Development of PE

1. NGT/OGT

2. Fluid warmer

3. Blood available

T&S are valid for 3 months if no transfusion/pregnancy history.

T&S are valid for 3 days if pregnant or pt transfused.

T&C should only be ordered if you anticipate transfusion (requested units are taken out of inventory)

• Remove from vent mode (manual/bag)
• Increase volatile agent (if stable)
• Give fentanyl (if stable)
• May give relaxants after checking twitches

1. Adhesions if previous surgery

2. Hypotension during manipulation

3. Hypotension after peritoneum is opened

4. Anticipate hypotension (fluids)

1. Large 3rd space loss

2. Hypothermia

3. Ureteral damage

4. Suction of obstructed bowel may require additional fluids

1. Hypoventilation from splinting

2. Hypoxemia from splinting

3. Ileus from manipulation and narcotics

Appendicitis is caused by an obstruction of the appendiceal opening.

Infection with perforation and peritonitis are complications of an appendectomy.

Hyperplasia of submucosal lymphoid - 60%

Fecal stasis - 35%

1. Pneumoperitoneum

2. CO2 insufflation

1. Consider volume status when choosing agents.

2. Consider myopathy in children, especially in males

1. Sepsis

2. Paralytic ileus

3. Atelectasis

4. Aspiration during emergence

5. Prolonged muscular blockade (aminoglycosides)

1. Massive volume resuscitation (main cause)

2. Inflammatory state with capillary leak, fluid sequestration, inadequate perfusion and lactic acidosis.

What is IAP during spontaneous respiration? Hospitalized supine pt?

IAP 0 mmHg in spontaneous respiration

IAP 6.5 mmHg baseline in hospitalized supine pt.

Grade 1: 10-15 mmHg: Maintenace of normovolemia

Grade 2: 16-25 mmHg: Volume administration

Grade 3: 26-35 mmHg: Decompression

Grade 4: >36 mmHg: Re-exploration

Hepatic artery and hepatic vein

It receives 25-30% of the CO.

How much ml/min does the liver receive? What percentages are from the portal vein and portal artery?

Where does the liver get its oxygen from?

The liver receives about 1500 ml/min of blood.

75% of blood portal vein, 25% of blood portal artery.

50% of O2 from portal vein, 50% of O2 from portal arteries.

1. Hypotension

2. Hypovolemia

3. Hypoxia

4. Hypercarbia?

5. Light anesthesia

1. Bile production

2. Glycogen storage

3. Drug biotransformation

4. Coagulation (all factors are produced except VIII)

5. Vit K Deficiency due to impaired production of PT (II), VII, IX, and X

1. Head of pancreas

2. Portion of bile duct

3. Gallbladder

4. Duodenum

5. Portion of stomach

Vena cava clamping - Increase HR and BP

Vena cava unclamping - Decrease HR and BP

Increase gas when they are about to clamp, don't overlaod on narcotics bc when they unclamp you'll be stuck with it.

1. Blood MUST be in the room.

2. Coagulopathies corrected?

3. Regional is NOT appropriate.

Keep CVP <5 cmH2O to reduce blood loss during dissection.

Suspect air embolism if CVP falls too low or pt is suddnely hypovolemic.

1. RSI if ascites

2. Reduced drug doses due to hepatic/renal dysfunction

NOOOOOO.

Cell saver is only appropriate in NON-CANCER cases.

Carcinoid tumor = Slow growing malignancy of chromaffin cells.

Can be located in liver, pancreas, lung, and thymus.

More commonly located in the small intestines, rectum, and stomach.

1. 5-hydroxyindoeacetic acid (5-HIAA) in the urine

2. CgA (Chromogranin A) in the serum.

1. Bronchospasm (histamine release)

2. SVT and tricuspid regurgitation

3. Hypotension, decreased CO, flushing (bradykinin release)

4. Abd pain, diarrhea (serotonin release)

5. Hyperglycemia (serotonin mimics epi for glycogenolysis and glycogenesis)

1. CV collapse due to release of vasoactive mediators.

2. Bronchospasm

3. Cardiac right heart involvement (tricuspid insufficiency)

4. Autonomic stimulation

5. Electrolyte imbalance

1. Stress

2. Tumor manipulation

3. Physical stimulation

Octreotide!!

It's a somatostatin (GH) analogue.

Should be started 2 weeks preoperatuively (do NOT stop)

1. Evaluate for carcinoid syndrome

2. Correct CV instability (volume)

3. Premedicate (to minimize tumor mediator release)

4. Avoid triggers (anxiety, pain, hypoxia, hypercarbia)

5. Avoid drugs that cause histamine release (ketamine, morphine)

Determine the cause: manipulation or beta stimulation?

Stop the manipulation, give 100% FiO2.

Reduce volatile agent with hypotension, restore vascular volume.

Give drugs to decrease mediator release (octreotide, esmolol, avoid ephedrine due to alpha/beta stim.; use neo instead)

Corticosteroids, atrovent and antihistamines.

Do NOT give epi or theophylline, these worsen the bronchospasm.

1. Keep their "tanks fulls"

2. Keep patient warm

3. Normocapnia

4. Normocarbia

5. Avoid all histamine releasers