Download - Anaesthesia for Laparoscopic Sx
ANESTHESIA FOR LAPAROSCOPIC SURGERIES
Prepared & Presented By:Dr. ROSHANA MALLAWAARACHCHI
AIMS
To review the history of laparoscopic surgeries.
To discuss, briefly, the basic principles of laparoscopic surgeries.
To discuss the physiological consequences of laparoscopic surgeries.
To discuss the complications (management) of laparoscopic surgeries.
To discuss the anesthetic management of laparoscopic surgery.
HITORICAL NOTES
1980: Patrick Steptoe (UK): started laparoscopic procedures.
1983: Semm (German gynecologist): performed the first laporoscopic appendectomy.
1985: Erich Muhe (Germany): 1st reported lapaorscopic cholecystectomy.
1987: Ger: lap repair of inguinal hernia.
HISTORICAL NOTES (…CONTD.)
1987: Phillipe Mouret (France): 1st Laparoscopic Cholecystectomy using video technique
1988: Harry Reich: laparoscopic lymphadenectomy for t/t of ovarian cancer.
1989: Harry Reich: first laparoscopic hysterectomy using bipolar dissection.
1990: Bailey and Zucker (USA): laparoscopic anterior highly selective vagotomy with posterior truncal vagotomy.
ADVANTAGES OF LAPAROSCOPIC SURGERY
Less postoperative pain
Less postoperative pulmonary impairment
Less incidence of postoperative ileus
Shorter hospital stay
Earlier ambulation
Smaller surgical scars
LAPAROSCOPIC PROCEDURES (GENERAL) Cholecystectomy Vagotomy Appendectomy Colectomy Inguinal hernia repair Adrenalectomy Nephrectomy Prostatectomy Pancreatectomy
Bariatric surgery Nissen fundoplication Para-esophageal
hernia repair Splenectomy Liver resection Cystectomy with ileal
conduit
LAPAROSCOPIC PROCEDURES (GYNECOLOGIC)
Ectopic pregnancy Ovarian
cystectomy Reversal of
ovarian torsion Salpingo-
oophorectomy Hysterectomy
Myomectomy Sacrocolpopexy Lymphadenectomy Lymphadenectomy
, staging Ablation of
endometriosis
SURGICAL STEPS
Introduction of ‘Veress Needle’
Creation of pneumoperitoneum
Electrocautery dissection
GASES USED TO CREATE PNEUMOPERITONEUM: WHY IS CO2 PREFERRED??
HeliumInsoluble, gas embolism
Argon
N2O: Supports combustion, diffuses into the bowel, PONV
CO2: Soluble in blood, Risk of gas embolus is reduced. Safe during electrocautery (Non-flammable) Can be easily eliminated through the lungs Rapidly absorbed into the bloodstream Inexpensive
PROPERTIES OF IDEAL GAS FOR INSUFFLATION
Colorless
Limited systemic absorption across the peritoneum
Limited systemic effects when absorbed.
Rapid excretion if absorbed
Incapable of supporting combustion.
High solubility in blood.
Limited physiological effects with intravascular systemic embolism
PHYSIOLOGICAL EFFECTS OF LAPAROSCOPY
Minimally invasive surgery is not minimally stressful!
MAJOR FACTORS RESPONSIBLE FOR ALTERATION IN PHYSIOLOGY
Pneumoperitoneum
Positioning
Systemic absorption of Carbon dioxide
EFFECT OF PNEUMOPERITONEUM (MECHANICAL EFFECTS)
RESPIRATORY & VENTILATORY CHANGES
Increased Intra-abdominal pressure
Upward displacement of diaphragm/Impaired diaphragmatic movements
Reduced lung compliance & FRCIncreased airway pressure & barotrauma
V/Q mismatch with hypoxemia & hypercarbiaCompression of basilar lung segments &
atelectasis
HEMODYNAMIC CHANGES
↑Intra-abdominal Pressure
↓Venous return & ↑SVR
↓ Cardiac Output & Cardiac Index
CNS
1) ↑ Intrathoracic pressure2) ↑ PaCO2 & ↑CBF
3) Compression of IVC, ↑ lumbar spinal pressure &↓ CSF drainage
↑ ICP
HEPATOPORTAL
? ↓ Gastrointestinal (Splanchnic) blood flow Mechanical compression ADH Superior mesenteric artery
constriction
? Maintained Splanchnic blood flow Hypercarbia Vasodilation
RENAL
Decrease in renal blood flow when IAP >15 mmHg Decrease in GFR Decrease in urine output Decrease in creatinine clearance Decrease in sodium excretion Potential for volume overload in the face of
excessive fluid administration.
LOWER LIMB
1) ↓ Femoral venous blood flow
2) Pooling of blood (Reverse Trendelenberg position)
↑DVT
EFFECT OF PNEUMOPERITONEUM ON PHARMACOKINETICS
Prolonged T1/2 of drugs eliminated by liver (reduction of hepatic perfusion)
Reduced Clearance of drugs eliminated through kidneys (reduced creatinine clearance and urine flow)
NEUROHUMORAL RESPONSES
RAA system activation (↑ renin, ↑ angiotensin, and ↑ aldosterone)
Sympathetic system activation (↑ catecholamines)
EFFECT OF POSITIONING
Friedrich Trendelenburg 1844-1924
EFFECTS OF POSITIONING
Position varies according to the anatomical site of operation Trendelenberg position
Pelvic procedures
Reverse Trendelenberg position
Supremesocolic procedures (e.g., Cholecystectomy)
Associated changes are related to: Degree of head-down/up
tilt Patient’s age Intravascular volume
status Associated cardiac
disease Ventilation techniques Anesthetic drugs
EFFECTS OF TRENDELENBERG POSITION Cardiovascular System
↑ CVP & CO Baroreceptor reflex vasodilation and
bradycardia Usually insignificant in healthy patients
Patients with coronary heart disease with poor left ventricular function - ↑ central blood volume, and pressure changes maybe harmful.
EFFECTS OF TRENDELENBERG POSITION Respiratory System
Facilitates the development of atelectasis FRC, total lung volume, and pulmonary
compliance is reduced.
CNS ↑ CBF
↑ ICP ↓ Venous return
EFFECTS OF REVERSE TRENDELENBERG POSITION
Cardiovascular System Venous return thus reducing CO and MAP
(compounded by the pneumoperitoneum) Venous stasis occurs in the legs
Respiratory System Increased FRC
EFFECTS OF CO2 INSUFFLATION
Direct Effects: Hypercarbia, Acidosis Decrease in HR, contractility, and SVR.
Indirect Effects (stimulation of SNS) Increase in HR, contractility, and SVR.
Premature ventricular contractions
Bradydysrhythmias
Asystole
COMPLICATIONS OF LAPAROSCOPY WITH RELEVANCE TO ANESTHESIA
Cardiovascular: Hypotension, hypertension, tachycardia, bradycardia, dysrhythmias,
asystole Pulmonary:
Hypercapnia, hypoxemia, atelectasis, barotrauma Related to gas insufflation
Subcutaneous emphysema, gas embolism, pneumothorax, pneumomediastinum, pneumopericardium, extreme CO2 absorption
Surgical Hemorrhage, damage to hollow viscera, damage to nerves
Mechanical Damage to nerves or eyes (positioning and draping), dislodgement
of ET tube with endobronchial intubation Miscellaneous:
Hypothermia, nausea and vomiting, hyperkalemia, renal failure, increased risk of regurgitation
Foramen Bochdalek
Foramen of Morgagni
Paraesophageal hiatus
Subcutaneious Emphysema
Subcutaneous Emphysema
GAS EMBOLISM: DETECTION
Fall in ETCO2 Dysrhythmias (bradycardia, tachycardia,
asystole) Hypotension (decreased left ventricular filling) Fall in arterial oxygen saturation Increased CVP and venous congestion ECG evidence of acute right heart strain Mill-wheel murmur Precordial Doppler, TEE, Transthoracic
echocardiography
GAS EMBOLISM: TREATMENT
Stop gas insufflations immediately Increase inspiratory O2 concentration to 100%
and hyperventilate Position patient head down, left lateral
decubitus Attempt intracardial gas aspiration if CVP
present Give inotropes to support right ventricle Treat severe hypotension with vasopressors CPR for asystole
DYSRHYTHMIAS
Tachycardia, bradycardia, asystole
Identify the cause
Stop gas insufflation
Consider Atropine (may need to give undiluted atropine)
Don’t delay CPR
ENDOBRONCHIAL INTUBATION
Carina shifts upwards with creation of pneumoperitoneum Exaggerated by positioning (head down)
Check tube position frequently
HYPOXEMIA Pre-existing conditions: morbid obesity, COPD
Hypoventilation: positioning, pneumoperitoneum, ET tube obstruction, bronchospasm, inadequate ventilation, gas embolism.
Intrapulmonary shunting: decreased FRC, endobronchial intubation, pneumothorax, atelectasis.
Decreased Cardiac Output: hemorrhage, dysrhythmias, myocardial depression.
Technical equipment failure: circuit disconnection, delivery of hypoxic gas mixture.
HYPERCARBIA
Excessive absorption of CO2 Hypoventilation Increased dead space CO2 embolism Pneumothorax, pneumomediastinum,
pneumopericardium Subcutaneous emphysema Exhausted CO2 absorber Malignant hyperthermia
ANESTHESIOLOGICAL CONTRAINDICATIONS OF LAPAROSCOPY
Congestive heart disease (NYHA II-IV) Ischemic heart disease Obstructive and restrictive pulmonary diseases Morbid obesity Pregnancy Patent foramen ovale Huge organomegaly Moderate to severe ascites Right-to-left shunt
ABSOLUTE CONTRAINDICATIONS
Acute or recent MI
Blood dyscrasias
Late 2nd trimester of pregnancy
Uncompensated COPD
Hiatus hernia
CONDUCT OF ANESTHESIA
Pre-anesthetic check-up & Pre-op advice
History, physical examination, risk assessment.
Premedication: H2-blocker, Anxiolytic (midazolam/diazepam)
CONDUCT OF ANESTHESIA
Goals: IAP: 12 – 15 mmHg (don’t allow to rise >20 mmHg) Airway pressure <40 cmH2O (20 – 30) EtCO2 ~ 35 mmHg Maintain BP and HR.
Give attention to Prevent Acid Aspiration ET tube displacement Rhythm changes esp. at the time of gas insufflation PONV prophylaxis Post-operative pain management
Patient may be anxious
Duration may be long
Trendelenburg position (with pneumoperitoneum) may cause respiratory compromise and dyspnea in the awake patient
Muscle relaxation is invariably needed.
LMA, & spontaneous breathing not recommended.
Induction: Injection Pethidine 0.5 – 1 mg/kg; then inj Propofol (1.5 – 2 mg/kg) or STP (5 mg/kg); Succinylcholine (vecuronium, rocuronium, cisatracurium) + Inj Dexamethasone 4 mg iv for PONV prophylaxis
Intubation: appropriate size cuffed ET tube (LMA not recommended). NG or OG tube insertion and aspiration of stomach content (air)
Maintenance: Isoflurane (or TCI of TIVA) + O2 + Muscle relaxant ;
Ventilation: O2 + IPPV (spontaneous ventilation not recommended) adjusted to eliminate CO2
End of the Sx: Give inj ondansetron 4 mg; stop isoflurane when instruments are removed; slightly reduce ventilation, allow the patient to breathe spontaneously (but avoid hypoventilation); Reversal agent
Halothane (+ fentanyl) not recommended.
Extubation
Watch for facial edema
Watch for subcutaneous emphysema
Inspect oropharynx
POSTOPERATIVE MANAGEMENT
Issues:
Pain: wound/ right shoulder
PONV
PROTOCOL FOR POSTOPERATIVE PAIN RELIEF
Preoperative administration of a non-opioid analgesic (e.g. NSAID, Paracetamol)
Pre-incisional infiltration of trocar insertion sites with local anesthetics (e.g. 40 ml bupivacaine 0.25%, lidocaine 0.5%)
Rescue medication with small doses of an opioid (e.g. morphine)
Treat postoperative shivering with clonidine or pethidine.
PONV
Incidence as high as 42%.
Inj Dexamethasone 4 mg iv at the time of induction.
Inj Ondansetron 4 mg iv at the end of surgery.
Third anti-emetic for rescue therapy.
Adequate pain control.
Recent Advances
GASLESS LAPAROSCOPY
SINGLE-PORT LAPAROSCOPIC SURGERY
Less postoperative pain, less blood loss, faster recovery time, and better cosmetic resultsDrawbacks - increased operative time
Thank You