1

How to make a friend of your laparoscopic surgeon?

JPMulier 2012

1150 1850 1947 1977 2013

Jan Paul Mulier MD PhD Anaesthesiologist

Sint-Jan Brugge, Belgium

Can we do something to improve the situation?

  Surgeon: The abdomen is flat, I have no space to operate.

  Anesthesiologist: your problem. The patient is sleeping enough and I am oke.

  Surgeon: Look at the video screen. How do you think I should work!

  Anesthesiologist: The patient will not tolerate higher pneumoperitoneum pressures. An experienced surgeon can handle this.

  Surgeon: But it is already 18 mmHg. Do you want me to change to a laparotomy? Did you give NMB by the way and why should I always have to ask that?

  Anesthesiologist: The patient has only one TOF response in the AP. Last time this was enough. Why not today with you?

  Surgeon: I don’t know what “one TOF response” means. What I said is I can´t work with you. Call your supervisor!

2

Intraabdominal pressure ? Intraabdominal volume?

Workspace?

CAPE 2013

2

Insufficient lap workspace: how surgeons recognize it?

  At the first insufflation with the verres needle   High abdominal pressure to start > 10 mmHg.   No flow is going inside.

  Insufficient space to reach certain areas   Flat abdomen, no view

  Patient start to press suddenly   Abdominal wall, diaphragm movements   ventilator alarm

  Coughing or breathing against ventilator   insufflator alarm

  IAP sudden > set pressure.

  PSVentilation is not noted by the surgeon!   Ventilator synchrony with patient!

3

CAPE 2013

1.  Apple sized persons, most frequent male.

2.  Women who have never been pregnant.

3.  First laparoscopy.

4.  Max weight at moment of surgery.

5.  Abdominoplasty

6.  No hip flexion possible

7.  No deep NMB possible

8.  Reasons to breath against ventilator JPMulier 2012

4

Prediction of insufficient workspace:

JPMulier 2012

5

Example of insufficient workspace

PV loops with fit

0

10

20

30

40

-0,5 0 0,5 1 1,5 2 2,5

IAV liter

IAP

mm

Hg

IAP

1.  No muscle relaxation

2.  Active contraction against ventilator

3.  Full muscle relaxation

051015202530354045

0 500 1000 1500 2000 2500 3000

IAP

mm

hg

-0,5

0

0,5

1

1,5

2

2,5

IAV

liter

IAPIAV

no relaxation valsalva contract relaxation

1 2 3

2 1 3

Example: 1,2 L versus 7,2 L

JPMulier 2012

6

Maximal NMB helps but is not sufficient alone NMB needed? Depends on the IAP used?

JPMulier 2012

7 Why this difference: Patient variability   Inflated volume at 15 mmHg without NMB varies from 0,5 L to

10 L.

  Who needs NMB?

  Will the surgeon be comfortable?

0

2

4

6

8

10

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33

infl

ated

Vol

ume

liter

patient nr

Variability of inflated abdominal volume at 15 mmHg pneumoperitoneum

without NMB

Compliance (C) and Elastance (E) C=change in V/change in P (C= 1/E)

PV0 = 5

E = 4 mmHg/l

Higher insufflation pressures needed

J Mulier, B Dillemans, M Crombach, C Missant, A Sels On the abdominal pressure volume relationship. The Internet Journal of Anesthesiology. 2009; 21: 1.

Insufficient intra abdominal volume

8

JPMulier 2012

Three point calculation before after leg flexion

9

JPMulier 2012

10

Effect of leg flexion on APVR

PV0 4,320 = 4,76571

E 3,459 > 2,66067

5,037 = 4,91096

3,368 > 2,577

• PV0 no change • E decreases

Mulier JP Obes Surg 2009 JPMulier 2012

Three point calculation before after deep NMB

JPMulier 2012

11

Use of NMBA is Associated With Decreased Frequency of Poor Surgical View Conditions1,a

1. King M. Anesthesiology. 2000;93:1392–1397.

a In a randomized, blinded, placebo-controlled study of 120 patients undergoing radical retropubic prostatectomy, patients received an infusion of NMBA (n=59) or saline (placebo, n=61) beginning 5 minutes after fascial incision. At 15 minute intervals, the surgical field was graded from 1 (excellent) to 4 (unacceptable). Patients who were graded as having an unacceptable surgical field received rescue NMBA.

Placebo n=61

NMBA n=59

P<0.001 placebo vs NMBA

% P

atie

nts

wit

h po

or

surg

ical

vie

w c

ondi

tion

s

NMBA=neuromuscular blocking agent. JPMulier 2012

12

Difference Between Diaphragm and Adductor Pollicis

•  Monitoring of the peripheral muscles often overestimates the degree of diaphragmatic relaxation, but is a safe predictor of recovery. •  Moerer O. Anasthesiol Intensivmed Notfallmed

Schmerzther. 2005;40:217

•  The diaphragm is more resistant than the adductor pollicis to rocuronium and has a faster recovery of the twitch height. •  Cantineau JP Anesthesiology. 1994;81:585

13  

JPMulier 2012

Time difference when bolus NMB given between abdomen – adductor pollices

Kirov K et al. Ann Fr Anesth Reanim. 2000;19:734–738.

Sensibility to atracurium of the lateral abdominal muscles Objective: To study the effect of atracurium on the electromyographic activity of the lateral abdominal muscles and adductor pollicis in anaesthetized subjects.

Lateral abdominal muscles blockade have a faster onset and recovery than adductor pollices

JPMulier 2012

14

Solution to Both Problems: Continuous Infusion to a Deep Block

Deep NMB could remain in place for duration of procedure

followed by rapid predictable reversal

JPMulier 2012

15

JPMulier 2012

16

BMI effect on abdominal P/V relation

-4

-2

0

2

4

6

8

10

0 10 20 30 40 50 60

PV

0 in

mm

Hg

BMI

Effect of BMI on PV0

0

0.002

0.004

0.006

0.008

0.01

0.012

0 10 20 30 40 50 60

E in

mm

Hg/

l

BMI

Effect of BMI on E

  J Mulier ISPUB 2009   Pressure volume relation is linear

  PV0 and E are patient determined

  J Mulier IFSO 2007

JPMulier 2012

17 Two types of android obesity

Intra visceral adiposity Extra visceral adiposity

Subcutaneus fat is scant and Subcutaneus fat is thick and

intra abdominal fat is thick and intra abdominal fat is scant.

Subcutaneus Fat Visceral fat -­‐50

0

50

0 0, 5 1 1, 5 2 2, 5 3 3, 5 40

0, 5

1

1, 5

0 0, 2 0, 4 0, 6 0, 8 1 1, 2

abdominal pressure in android shape with intra visceral fat

0

5

10

15

20

25

0 1 2 3 4IAV in liter

IAP

in m

mH

g

Thicness of external fat

JPMulier 2012

18

Other techniques used to improve surgical wokspace and access:

1.  Patient position Beach chair, anti trendelenburg improves access to upper abdomen even if workspace declines.

2.  Higher intra abdominal pressures Max 20 mmHg possible

3.  Standardisation of surgical procedure Know what to do

4.  Short overstretching of abdomen at moment of difficult access. ARM procedure.

5.  Weight reduction with modifast to create abdominal space.

JPMulier 2012

19

Patient 3   53 years old woman with a BMI of 56 and TBW of

145 kg and a length of 1, 61 m.   She was never operated before but has 4 children after

which she gained a lot of weight. The WHR is 0,98 but most fat is sitting outside around the abdomen.

  Intermediate NMB (TOF = 3)

 The measured abdominal compliance is normal and around 0,4 liter/mmHg but the PV0 is +12 due to the obesity.

 What would you do?   High PV0 and normal compliance

0  

5  

10  

15  

20  

25  

0   1   2   3   4   5   6  

IAP  m

mHg  

IAV  liters  

APVR  of  patient  3  

pat  3  

0  

5  

10  

15  

20  

25  

0   1   2   3   4   5   6  

IAP  m

mHg  

IAV  liters  

APVR  of  patient  3  

pat  3  

pat  3  deep  NMB  

Patient 3 PV0 = 0 E = 0.2 L/mmHg

  To get a volume of 4 liters we need an IAP of 12 + 4/0,4 = 22 mmHg.

  Deep NMB allowed the PV0 to drop to 8 and the IAP to 18 mmHg.

  The surgeon has now plenty of space and some moments we are able to drop the pressure to 15 when he can work in 3 liters.

  Without deep NMB the surgeon would have only 1,4 liters at 15 mmHg IAP and would have to struggle to operate.

Patient 4   58 Years old man of 178 cm and 154 kg TBW.   intra abdominal obesity (WHR = 1,06),   He did a lot of sports 10 years ago but became inactive and

gained weight. His BMI is now 48,6.   No abdominal operation in the past.

 The measured abdominal compliance is 0,15 liter/mmHg and the PV0 is +13 mmHg.

 What would you do?   High PV0; non compliant abd

0  

5  

10  

15  

20  

25  

0   1   2   3   4   5   6  

IAP  m

mHg  

IAV  liters  

APVR  of  pt  4  

pat  4  

0  

5  

10  

15  

20  

25  

30  

35  

40  

0   1   2   3   4   5   6  

IAP  m

mHg  

IAV  liters  

APVR  of  pt4  

pat  4  

pat  4  deep  NMB  

Patient 4 PV0 = 13 E = 0.15 L/mmHg

  To get a volume of 4 liters we need an IAP of 13 + 4/0,15 = 40 mmHg.   Deep NMB drops the PV0 to 10 but the IAP to achieve 4 liters is still 36

mmHg.   The surgeon might be able to work in a small workspace ? At 20 mmHg,

1,5 l.   Peep, anti trendelenburg reduce the space, but less peep is not an

option.   permissive hypercapnia with smaller tidal volumes but this has a

limited value.   Hip flexing rises the compliance to 0,2 and gives 500 ml at IAP of 20

mmHg.   Switch to an open laparotomy, cancel the case and request the patient

to loose at least 10kg body weight or request to increase shortly the IAP above 20 mmHg.

Methods to improve surgical wokspace.

1.  Deep NMB NMB reduces PV0 and increases workspace with 0,5 to 2 liters.

2.  Patient position Beach chair increases C and increases workspace with 0,5 liter.

3.  Higher intra abdominal pressures Max 20 mmHg possible workspace increase dependent of C

4.  Standardisation of surgical procedure Know what to do in less space

5.  Short overstretching of abdomen at moment of difficult access.

1 liter extra possible for a short moment.

6.  Weight reduction with prowell/modifast to reduce PV0. Increase with 1 liter.

CAPE 2013

24

Yes we can do something move the blood brain barrier down

  Surgeon: Now I can work and I have enough space.

  Anesthesiologist: the patient is OK.

  Surgeon: Look at the screen. The patient is relaxed and you gave me a low IAP.

  Anesthesiologist: the patient is now on a deep neuromuscular block with a continuous infusion.

  Surgeon: thanks, then we will end in time and we can have a drink together

25

CAPE 2013

25

Measure to know who needs deep NMB.

CAPE 2013

26

Your surgeon your friend ? ask him to help you

We learn our surgeons to handle us different?

  ‘Ask not only what the anaesthesiologist can do for you, ask also what you can do for your anaesthesiologist.’

02/06/13 ESA 2013 O5RC1 J P Mulier

27

December 14th 2013Crown Plaza, Burg 10Bruges, Belgium.

4thESPCOP

meeting

Does Anaesthetic technique affect outcome in the morbidly obese patient? This meeting addresses many aspects of peri-operative care for the obese

patients, and amongst these will be particular focus on atelectasis, opioids, NMB and epidurals. Each lecture will discuss pathophysiology

and the practical consequences for us in our daily clinical work.