General/Uro/Gynae
Operations
Clinical
Laparotomy
Ovarian malignancy
Pre-operatively
Airway
Ascities > reflux risk
Respiratory
Effusions - assess exercise tolerance ?pre-op drain
Reduced FRC and V/Q mismatch
Cardiac
Paclitaxel & cisplatin cardiotoxic effects
Exercise tolerence
Pericardial effusions
Indwelling venous access?
Pharmacology
Paclitaxel & Cisplatin
Bone marrow suppression
Renal damage
LFT derrangemnet
Cardiotoxic
Diuretics
Antiemetics
Opioids
Haem
DVT risk
Liver dysfunction causing altered coagulation
Bleeding risk!
Micro
Marrow suppression
Renal
Chemotherapy damage...drug choices?
Liver
Chemotherapy damage....drug choices?
Nutrition
Malnutrition and dehydration risks
Postoperatively
Intraoperatively
CVS
Airway
Intubate - long, head down, abdominal, aspiration risk
Respiratory
Reduced FRC - good pre-ox with head up
Capnography and ABGs to target normal parameters
2 x large access ?CVC
A line
Cardiac output monitoring
Neuro
Pain - ?avoid PCM & NSAIDs ?epidural ?rectus sheaths
Haem
Bloods loss, ooze, coag abnormalities
DVT risk
Micro
Bonemarrow suppression - asepsis required
MSK
Care with positioning, ?bony mets
Renal
Catheterise
Drug choice
Metabolic
Long surgery - measure temp
ABG for lactate etc
Where?
Level 2 or 3
Resp
Oxygen support (esp as PCA)
CVS
?CO to guide IVF
Neuro
Pain Mx - acute pain team
Haem
DVT risk
Renal
U/o to guide fluids
Nutrition
Entral nutrition asap
Laparoscopy
Risks
Trocars
Visceral or vascular injury
CO2 embolus
Surgical emphysema
Head up position
Airway - accidental extubation
CVS - venous pooling, reduced venous return, hypotension
Neuro - reduced CPP
MSK - pressure points, pt movement
Pneumoperitoneum
Resp
Reduced FRC
Increased PaCO2 due to absorption
Barotrauma risk if using elevated pressures
CVS
Inflation causes autotransfusion from splanchnic vessels
IVC compression reduces venous return, SV falls, causing tachycardia
Aortal compression release humoral factors which increases SVR and CO -> increased myocardial workload
Neuro
Raised CO2 - cerebral vasodilation
CO reduced in head up position - reduced CPP
GI
Reflux risk
Compromised splanchnic flow
Haem
Venous stasis, DVT risk
Renal
Raised intra-abdo pressure - raised renal vascular resistance, reduced GFR and u/o
Minimising risks
Patient selection - CVS/RS reserve
Good surgical technique - reduced pressure/duration etc
A
Check tube position after moving/insufflation
B
Intubate, PPV, PEEP
C
Adequate volume, ionotropes>vasopressors
G
Consider a-line
Minimise FMV to reduce aspiration risk. Consider NGT to deflate stomach
Phaeochromacytoma
Characteristics
Symptoms
SoB/Reduced ET/orthopnoea
Palpitations/anginal CP
Headache/anxiety/visual disturbance
Nausea/vomiting/abdo pain
Sweating
Signs
Crepitations on chest
HTN/tachycardia/tachyarrhythmia
Tremor/HTN enchephalopathy/seizures/change in GCS
Weight loss
Investigations
Biochemical
Plasma & urine metanephrine, normetanephrine, dopamine & homovanillic acid
Radiological
MRI/CT confirm after biochem Ix
MIBG (meta-iodobenzylguanidine) scan assess extra adrenal tumours. MIBG is taken up by adrenergic neurones so concentrates in phaeos
General
Catecholamine secreting neuroendocrine tumours
Can be malignant (spread to liver), genetic (auto dominant/MEN/neuroectodermal dysplaisia ie Von Hippel-Lindau)
Secrete NA>A>dopamine (familial ones secrete adrenaline mostly)
Treatment
Pre operative
Alpha blockers
Overall
Reduce BP
Reduce SVR
Increase filling
Control tachycardia
Improve cardiac function
1 or 2 weeks preop
Reduce BP, increase intravasc capacity - pts need filling, reduce afterload, reduces surges with tumour manipulation
Non selective (phenoxybenzamine)
Irreversible
Blocks A1 so stops BP surges
Blocks A2 - prevents presynaptic NA reuptake so uninhibited release and tachycardia via B1
Stop a couple of days before operation
Selective A1
Doxazosin/Prazosin
Avoids tachycardia but are competetive so can be overwhelmed (by tumour handling)
Calcium channel blockers
Used in addition with A blocker if HTN resistant or solo if HTN is mild
Block NA-induced Ca2+ influx
Beta blockers
Control tachycardia (from A block or catecholamine release)
Start AFTER alpha blockers or B2 vasodilatory block cause worsening of HTN (with NA acting on alpha receptors, while heart loses B1 inotropy -> dysfuntion/failure)
B1 selective - metoprolol or atenolol
Hodgkin's Lymphoma
Renal Transplant
Pre-operative
CKD
A
B
?scelroderma
Fluid overload
Immunosuppresion ?chest infection
Continuous ambulatory peritoneal dialysis (CAPD) - drain to avoid splinting etc
C
IHD, HTN, ?LVF
Fistulae/vascaths
Calcified valvular lesions
ECG/ECHO/CPEX
Neuro
Autonomic neuropathy (uraemia & diabetes)
Endo
DM - VRII
?Steroid Rx - will need increase
Secondary hyperparathyroidism
Pharm
?Avoid sux if raised K+
VRII
Omit ACE-Is or angioII inhibs
Continue immunosuppressants if on
Haem
Anaemia
?PPI ?RSI
Check FBC, G&S etc
Thrombocytopenia
Renal
Assess fluid status
Check electrolytes
Intra-operative
Optimising transplant function
A&B
Optimise GE
C
Optimise filling (CO monitor, CVP)
Aim normotension
Adequate warming
Endo
Glucose control
Renal
Avoid nephrotoxics
Post-operative
Pain
Paracetamol
Avoid NSAIDs
Wound catheters
PCA - fentanyl and oxycodone do not accumulate in renal failure
Epidural
avoid hypotension
watch coagulation
Drugs to avoid
NSAIDs
Reduce renal perfusion & function
Nephrotoxic
Morphine
Metabolised in liver to active m-6-G
Drowsiness
Hypotension
Resp depression
Codeine/Dihydrocodeine
Renally excreted active metabolites
TURP
TURP Syndrome
Cause
Excessive absorption of glycine irrigation fluid (1.5%)
15min - 24h after starting surgery
Volume shifts cause CVS compromise
Hyponatraemia and hypoosmolality cause neuro complications
Free water enters brain causing oedema
Raised ICP
Glycine (inhib NT) toxicity causes nausea/headache/transient blindness
NMDA potentiation
Seizures & encephalopathy
Can give Mg2+ as stabilises NMDA Rs
Clinical Features
B
Tachypnoea/hypoxia/pul oedema
C
HTN + bradycardia -> acute CCF -> CVS collapse
Broad QRS, TWI due to hyponat
Neuro
Burning sensation of hands & face
Absence of signs of high block
GI
Nausea & vomiting
Intra-operative risks
Pressure of irrigation (Bag>70cm above pt)
Large volume irrigation
Low venous pressure
Surgery >1h
Large blood loss (veins open)
Capulsar/bladder perforation
Management
Emergency - Call for help!
Inform theatre team, finish op asap and stop further irrigation
A&B
100% O2
Auscultate chest, check sats
Intubation if needed
?IV furosemide or mannitol
C
Atropine, inotropes, pressors as needed
Stop IVF
Check blood Na, osmolal and Hb
A line
D
Manage seizures with Mg2+ and lorazepam
If Na < 120 or severe Sx, give 3% NaCl to increase by 1mmol/h - else can cause CPM
Level 2 or 3 care for supportive Rx
Head down position
Airway - airway oedema, accidental extubation
Neuro - cerebral oedema
Breathing - FRC and V/Q mismatch are worse
Well leg compartment syndrome
Reduce arterial supply
Compression from bracing in position
Reduce venous return from pneumoperitoneum
D
Time at horizontal every 2h or so
General
Cancer of lymph system
Presentation
Lymphadenopathy, hepatosplenomeg
B symptoms
Fever, night sweats, weight loss, fatigue
Staging
1
Single LN
2
2 or more LNs
3
LN both sides of diaphragm
4
Disseminated involving extralymph organs (liver)
If B symptoms present add B, if not add A
Treatment
Chemo/radiotherapy
Splenectomy due to size or hypersplenism (excessive blood cell and platelet destruction)
Anaesthetic Mx
A
Upper airway compromise from LNs etc
Potential compromise from mediastinal mass
Compression at tracheal or bronchial level
Meticulous assessment (+CT or bronch)
Chemo can cause mucositis - delicate tissues
B
Atelectasis risk due to airway collapse
Bleomycin can cause toxicity if exposure to high O2 concs
C
Compression of vessels can cause CVS collapse
Dysfunction due to chemo
Damage to vessels and valves from radiotherapy - ?ECHO
Central line access?
Neuro
Nerve/SC compression
Peripheral autonomic neuropathies due to chemotherapies (?delayed emptying ?RSI)
GI
?malnourished
Haem
Pancytopenia
?RA appropriate
Blood loss?
Renal
Dysfunction (chemo), nephrotic syndrome (obstruction, infiltration of parenchyma, amyloid)
Liver
Dysfunction - coag issues, drug metabolism
Splenectomy Vaccinations
At least 2 but ideally 4-6w preop
Haemophilus B
Pneumococcus
Meningitis B & C
Annually
Influenza
Idiopathic Thrombocytopenia Purpura
Splenectomy
Immunological functions
Synthesis of Abs and immune proteins that allow phagocytosis
Removal of Ab covered blood cells and bacterium
Monocyte reservoir
Specialise into dendritic cells or macrophages
Patient populations
Trauma
Haematological malignancies
Pts require vaccinations (see below)
Pre-operatively
Understand disease state
Anaemia
Chemotherapy
Chronic disease
Malignancy
?HLA matched products
Steroids
MDT
Haem/Onc/ITU/Surgical/Anaesthetic/Radiology
Surgical technique
Traumatic
Midline incision
Good access, rapid assessment of other viscera
Haematological
Left subcostal incision
Laparoscopic
Anterior approach
Lateral approach
Pre-operative issues
A
Swollen tissues due to haematomas
Difficult airway, non traumatic technique needed
CVS
Aim for minimal BP surges ?Remi
Neuro
Analgesia
Avoid neuroaxial due to low platelets
Avoid NSAIDs
Avoid BP surges with straining on tube
Risk of spont ICB
Endo
?Periop steroids
GI
Risk of haemorrhage
Haem
?platelet transfusion
X matched blood available
Micro
ABx prophylaxis
MSK
Padding to reduce bruise/bleed risk
Conservative
Rationale
Avoids major surgery
Retention of some splenic function
Principles
Haemodynamicly stable pts
CT to grade splenic injury - lower grades more amenable
Local interventional radiologist available for angioembolisation etc
Absence of need for laparotomy for other reasons
Hyperchloraemic metabolic acidosis
Seen with neobladder formation
Can manifest following further surgeries
Biochemically
Hyperchloraemia
Metabolic acidosis with normal lactate
Hypernatraemia
Hypokalaemia, hypocalcaemia & hypomagnesaemia
Carcinoid
Presentation
Pathogenesis
Tumours from enterchromaffin cells (neuroendocrine origin) GI or lung
Contain neurosecretory granules of hormones & biological amines
Histamine
Dopamine
Corticotrophin
Substance P
Serotonin
Neurotensin
Prostaglandins & kallikrein
Normally asymptomatic as liver metabolises
10% develop carcinoid syndrome
Due to liver metastases & systemic relase of serotonin and vasoactive substances
Lachrymation
Bronchospasm
Flushing
R sided valvular HD (TS)
Diarrhoea
Anaesthetic considerations
Avoid B1 and vasopressor agents due to unpredictable effects
NA can activate kallikrein -> bradykinin release and paradoxical fall in SVR
Tumour handling can cause mediator release and drop in BP
Mx with octreotide 20-50mcg or vasopressin or carefully titrated phenylepherine
Ketaserin (seretonin antagonist) can help with flushing preop