ANESTHESIA IN LAPAROSCOPIC SURGERY WITH INTRA-OP HYPERCARBIA

Patcha Chatchawarat,MD.

WHAT ARE THE PRE-OP EVALUATION AND PREPARATION ?

(RESIDENT-1)

PREOPERATIVE EVALUATION AND PREPARATION

Patients history and PE Factors risk of pulmonary complications Investigation Specific information Additional procedure Premedicaiton Three major forces alter the pt.s physiology

PREOPERATIVE EVALUATION AND PREPARATION

Patients history and PE

general

condition
full stomach

intraabdominal mass

systemic

review esp.

severe heart disease Guideline respiratory disease Laparotomy renal failure nephrotoxic drugs
contraindications

ICP, hypovolemia,VP-shunt,gluacoma?

PREOPERATIVE EVALUATION AND PREPARATION

Factors risk of pulmonary complications

The

laparoscopic procedure itself Age:- esp. age>70 years Smoking/COPD Obesity Overdehydration
Anesthesia 1995;50:286-289

PREOPERATIVE EVALUATION AND PREPARATION Investigation

Basics

tests CBC,U/A, ECG, clotting functions and Blood T/S Renal function test and electrolytes Risk of pulmonary complication
PFT ABG CXR active disease, bullae, comparison of pre-op and post-op

ed).

(Miller RD,ed.Anesthesia,5 th

PREOPERATIVE EVALUATION AND PREPARATION

Specific information
general

complication

Laparoscopy Anesthesia

emergency

laparotomy post-op refered shoulder pain Inform consent

PREOPERATIVE EVALUATION AND PREPARATION

Additional procedure
Diet

clear liqiud diet,1 day before surgery NPO after midnight

complete bowel preparation antibiotic,as surgeon

Pre-op

PREOPERATIVE EVALUATION AND PREPARATION

Premedicaiton
Anxiolytic NSAIDs Clonidine

and sedative post-op pain & opioid

& dexmedetomidine the intra-op stress response and improve hemodynamic stability

PREOPERATIVE EVALUATION AND PREPARATION

Three major forces pt.s physiology

Pneumoperitoneum CO2 Position

alter the

esp.Trendelenburg

PATIENT MONITORING

Standrad monitor

ECG, NIBP, Pluse Oximetry, Capnography, Temperature

Invasive hemodynamic monitoring in severe heart disease & intra- thoracic P.

CVP PCWP Tranesophageal echocardiography A-line a-EtCO2

PATIENT MONITORING

Visual and tactile monitoring

skin

refill head, neck and upper chest a purplish color upper chest wall subcutaneous emphysema corneal and conjunctiva edema data of fluid volume& urine output oliguria

color, skin turgor, capillary

PATIENT MONITORING

Special devices
antiembolic

stockings shoulder braces a nasogastric or orogastric tube with suction&intermittent suction decompress stomach Foleys catheter

PATIENT POSITIONING

resident 2

PATIENT POSITIONING

Trendelenburg position down)

dorsolithotomy supine lateral rotation

(head
Gynecology Urology

Reverse Trendelenburg position (head up)

upper GI or biliary tract Sx. thorocoscopy, nephrectomy, and adrenalectomy

Lateral decubitus position

PATIENT POSITIONING

Respiratory

Head-down position

VC & FRC restrict movement of the diaphragm, esp. in obese and older Compliance V/Q mismatch cephalad movement of mediastinum

Head-up position

more favorable

PATIENT POSITIONING

Circulatory

Head-up position

Venous Return CO & MAP CO pneumoperitoneum&steep tilt venous stasis esp. with lithotomy healthy

Head down position

minimal change
VR & CO CVP,PCWP,SVR,and HR

CVS disease

CVP,PCWP CO VR&O2 demand

acute HF

PATIENT POSITIONING

Nerve injury
esp.

in head-down position Brachial plexus injury

Overextension Shoulder brace
Lower

extremity neuropathy

Common peroneal N.(in lithomy), meralgia, paresthesia, femaral neuropathy

Lower

extremity compartment syndrome

CHOICES OF ANESTHESIA

resident 3

ANESTHETIC TECHNIQUES

Local anesthesia
cooperation&relax IV

pt.

sedation avoid hypoventilation & desat. tubal ligation & diagnosis

Regional anesthesia General anesthesia

ANESTHETIC TECHNIQUES

Regional anesthesia
extensive

sensory block(T4-L5) sedative&narcotic muscle relax shoulder pain EDB with opioid +-clonidine pt.cooperation, experienced&skill surgeon, IAP&tilt, avoid for long procedure

ANESTHETIC TECHNIQUES

General anesthesia
with

cuff ET intubation with control ventilation long procedure anxiety patient Trendelenberg position risk of aspiration and perforation muscle relaxation
prevent bucking &coughing better surgical exposure

augment

ventilation to compensate for hypercarbia and resp.acidosis

GENERAL ANESTHESIA

BALANCED ANESTHESIA An inhalation agent

avoid

F3 esp.hypercarbia&hypoxia N2O----controversy

An antiemetic drugs
Droperidol,5-HT3

antagonist

A vagolytic drug
esp.

young females in hand

TIVA--propofol--awareness(Bis)

WHAT ARE THE POSSIBLE CAUSES OF HYPERCARBIA?

Resident 1

HYPERCARBIA

Hypoventilation CO2 in the inspired gas

rebreathing 3-6 mmHg/min

CO2 supply or production

hypermetabolic stateMH, fever, hyperthyroidism laparoscopy IV bicarbonate(50 mEq>1 L of CO2)

dead space (rare)

Pulm. embolism ventilation of lung cyst or advanced COPD

HYPERCARBIA

Factors in laparoscopy
Patients

with sig.cardiopulm. dis. Intraabdominal pressure>15mmHg Presence of subcutaneous emphysema Retroperitoneal rather than intraperitoneal approach Long duration

ANESTHESIA IN LAPAROSCOPIC SURGERY WITH INTRA-OP HYPERCARBIA

Patcha Chatchawarat,MD.

LAPAROSCOPIC SURGERY

a minimally invasive procedure allowing endoscopic access to the peritoneal cavity after insufflation of a gas (CO2) a gas space (the anterior abdominal wall-visceral organ) space the safe of manipulation of instruments and organs

The advantages and disadvantages

The advantages
The

cosmetic Non muscle-splitting incisions blood loss Less post-op pain and ileus Shorter hospitalization and convalescence Lower cost

The advantages and disadvantages

The disadvantages
The

long learning curve for the surgeon(the first 10 cases) The narrowed two-dimensional VF The need for GA The often longer duration Higher cost--sometimes

INDICATIONS

Urology
Uncomplicated adrenalectomy Nephrectomy

include live donor

Gynecology

Tubal surgery

sterilization,ectopic preg.

Cystectomy Hysterectomy Various abrations

endometriosis

INDICATIONS

General surgery
Cholecystectomy Hermia repair Antireflux procedure Splenectomy, appendectomy, bowel sx. Various upper and lower abdominal procedures

Thoracospic surgery Neurological intracranial Lumbar disectomy&other spine Sx.

anterior approach

Autopsy

CONTRADICATIONS

No absolute contraindications Relative contraindications

Coagulopathy Diaphragmatic

hernia Severe cardiopulmonary diseases (included bullae) intracranial pressure Space-occupying masses Impending renal shutdown A history of extensive surgery or adhesions

CONTRADICATIONS

Relative contraindications
Morbid

obesity Sickle cell disease

acidosis sickle crisis
Peritonitis A

large intraabdominal mass Tumor of the abdominal wall Hypovolemic shock A beta-blocked pt. Patient refusal

CONTRADICATIONS

Relative contraindication
VP

shunt Inexperienced surgeon strongest Pregnancy?

The Past contraindication Preserve fatal and maternal wellbeing and preterm labor Avoid hypercarbia and hypoxemia Pre-op and post-op fetal and uterine monitoring

The gas of choices = CO2

The Advantages
Nonflammable Not

support combusion Readily diffuses across membranes Rapidly removed in the lungs Highly soluble(buffering in RBCs)

H2O + CO2

carbonic anhydrase H2CO3

H+ +HCO3-

Small

risk of CO2 embolization

The gas of choices = CO2

The disadvantages
Not

inert very soluble in the absence RBCs and respiratory acidosis

Carbonic acid peritoneal irritation and pain during under LA Remain in gaseous from intraperitoneally after lap.sx. Shoulder pain The buffering capacity of blood exceeded

Not

Hypercarbia

Local

and systemic effects

HT,tachycardia,cerebral vasodilation, CO ,hypercarbia,respiratory acidosis

LAPAROSCOPIC SURGERY

Pneumoperitoneum

intraabdominal P.(IAP) & volume

Patient positioning
Trendelenberg

or lateral position The head-up position

Carbon dioxide
A

drug and a waste product Local tissue level Systemic effect

PNEUMOPERITONEUM

A blined or closed technique

2-mm diameter hollow Veress needle 1st trocar insert blindly CO2 insufflation

An open technique (previous sx. or adhesion)

A mini incision The blunt-tipped Hasson cannula The laparoscope is inserted CO2 insufflation

Abdominal distention

all 4 quadrants

Ventilatory and Respiratory changes

Ventilatory changes Increased in PaCO2 Respiratory complications

(Miller RD.ed,Anesthesia 5 th ed. )

Ventilatory changes

Compliance
Pneumoperitoneum 30-50% in healthy,obese,ASA III-IV Shape not change Patient tilting and MV

FRC
Elevation of diaphragm Change in the distribution of ventilation & perfusion Airway pressure

Physiologic dead space or shunt

IAP<14mmHg & tilting 10-20 degree in pt. Without CVS dis.

Increased in PaCO2

Absorption of CO2 from the peritoneal cavity V/Q mismatch: physiologic dead space
Abdominal distention Position of the patient(steep tilt) Controlled mechanical ventilation CO ( in sick pt.(obese,ASA II-III)

metabolism(insufficient plane of anesth)

Increased in PaCO2

Depression of ventilation by anesthetics(spont.breathing) Accidental events:

CO2

emphysema

subcutaneous or body cavity

Capnothorax CO2

embolism Endobronchial intubation

Respiratory complications

CO2-subcutaneousu emphysema Pneumothorax, pneumomediastinum, pneumopericardial Endobronchial Intubation Gas embolism Risk of aspiration

CO2-subcutaneousu emphysema

Accidental extraperitoneal insufflation VCO2, PaCO2 and PEtCO2 PEtCO2 after plateaued Treatment
Adjust

ventilation Interrupted CO2 insufflation A lower insufflation P. Post-op controlled ventilation until normocarbia

Pneumothorax,pneumomediastinum, pneumopericardial

Embryonic remnants
Right-sided

same way that ascites or PD

Defects in the diaphragm or weak point in the aortic and esophageal hiatus Pleural tears
In

fundoplicationLeft side

Pulmonary bullae

Pneumothorax,pneumomediastinum, pneumopericardial

Highly diffisible gas(N2O,CO2) Spontaneous resolution within 30-60 mi after exsufflation Guidelines

Stop N2O administration Adjust ventilator settings to correct hypoxemia Apply PEEP Reduce IAP as much as possible Maintain close communication with the surgeon Avoid thoracocentesis unless neccessary

ENDOBRONCHIAL INTUBATION

Pneumoperitoneum & head-down position The cephalad displacement of the diaphragm The cephalad movement of carina Leading to endobronchial intubation SpO2 & plateau airway P.

GAS EMBOLISM

Blind Veress needle insertion Clinical manifestation

abdominal cavity not distend equally in all 4 quadrants Hypotension, hypoxia, cyanosis, or cardiac arrest

Diagnosis
a mill-wheel murmur a sudden EtCO2 The most sensitives Precordial and transesophageal Doppler and tranesophageal echo. Definite diagnosis Aspiration of foamy blood from a CVP catheter

GAS EMBOLISM
Table 41.2 Differences Between Air and CO2 Emboli
EMBOLISM
Composition Position Origin Pressure source Solubility Effect of N2O

AIR
79%N2,21%O2 Sitting upright Vein open to air Hydrostatic Negligible Enlarge

CO2
100%CO2 Any No contact with air Insufflator Large Not enlarged

GAS EMBOLISM

Treatment
stop insufflation steep head-down and left lateral decubitus (Durant) position discontinuing of N2O 100% O2 hyperventilation definite Rx aspiration of gas or foamy blood from a CVP catheter

rapid recovery than air

a lethal dose > 5 times

RISK OF ASPIRATION

Might be considered IAP Head down position prevention

Hemodynamic promblems

In healthy Patients On regional Hemodynamics In high-risk Cardiac patients Cardiac Arrythmias

( Miller RD,Anesthesia,5th ed.)

Hemodynamic promblems

In healthy patients

IAP > 10 mmHg CO (10-30%) BP, SVR, PVR CO VR

significant

Hemodynamic promblems

Regional hemodynamics
Thromboembolic

complications

IAP& the head-up position venous stasis

Renal

function

Urine output, renal plasma flow, GFR Diuresis after desufflation

Hemodynamic promblems

Regional hemodynamics
Splanchnic

blood flow

Compensate by vasodilatation(CO2) If high IAP bowel hypoxia

ICP

If maintain normocarbia

not halmful

IOP

In healthy In eye disease

not change slightly

Hemodynamic promblems

In high-risk patients
qualitatively

similar quantitatively more marked low pre-op CO & CVP and high MAP&SVR Preventions
Pre-op preload low IAP(10mmHg) & slow insufflation rate(1L/min) Intra-op IV NTG(v.), nicardipine(a.)**, dobutamine

Hemodynamic promblems

Cardiac Arrythmias

PaCO2??(if with hypoxemia) Vagal tone bradycardia, cardiac arrhythmia, asystole

sudden streching of the peritoneum light anesthesia Pt. with beta-blockers electrocoagulation of the follopian tube Treatment easily and quickly reversible

Stop insufflation Atropine IV Deepening of anesthesia after recovery of the HR

Severe Cardiac diseases Gas embolism

Post-op Benefits and Consequences

Stress response Postoperative Pain Pulmonary Dysfunction Postoperative Neusea and Vomitting (PONV) ( Miller RD,Anesthesia,5th ed.)

Post-op Benefits and Consequences

Stress response
Acute phase reaction ( CRP& interleukin-6) Metabolic response Ileus & fasting endocrine response Adrenocortical stimulation Combined with EDB decrease Pre-op Alpha2-agonists

Post-op Benefits and Consequences

Postoperative Pain

Parietal pain

Moist peritoneal + CO2 biliary colic (LC) pelvic spasm (Tubal ligation) Shoulder-tip pain (diaphragmatic irritation) prolong procedure Topical anesthesia( LA in Intraperitoneal 80 mL of 0.5% lidocaine or 0.125% bupivacaine with epinephrine) Pre-op NSAIDs multimodal analgesia

Visceral pain

Neck and shoulder pain

Treatment

Post-op Benefits and Consequences

Postoperative Pain
Treatment

Topical anesthesia
Local

anesthetics in Intraperitoneal (80 mL of 0.5% lidocaine or 0.125% bupivacaine with epinephrine)

Pre-op NSAIDs

pain&opioid use

Pre-op multimodal analgesia

Post-op Benefits and Consequences

Pulmonary Dysfunction

Pulmonary function

less severe quicker recovery slower in obese, smokers,and COPD than healthy pt. remain impaired not improved

Diaphragmatic Function

Thoracic epidural analgesia

less impaired in gynecology laparoscopy

Post-op Benefits and Consequences

Postoperative Neusea and Vomitting (PONV)

a

high incidence (40-75%) delay discharge in OPD cases intra-op opioid use propofol anesthsia(TIVA) N2O??

Post-op Benefits and Consequences

Postoperative Neusea and Vomitting (PONV)

Prevention decompress

stomach Intra-op IV droperidol, odansetron and transdermal scopolamine intra-op opioid use

Postoperative management

Continue hemodynamic monitors

effect of CO2-pneumoperitoneum hyperdynamic state in cardiac pt.

O2 administration

PaO2 LC O2 demand RR & PEtCO2

early post-op

Prevention & treatment

PONV Pain important in OPD case

Alternatives to CO2peumoperitoneum

Inert gases
helium,

argon the low blood solubility hyperventilation not required ventilatory response( IAP) CO MAP

Gasless Laparoscopy

Alternatives to CO2peumoperitoneum

Gasless Laparoscopy
The peritoneal expanded by a fan retractor the hemodynamic and respiratory change from IAP & CO2 No alter renal and splanchnic blood flow PONV ( only! in LC) Port-site metastases interesting for severe cardiac or pulmonary disease pt. surgical exposure difficulty Combining with low CO2pneumoperitoneum (5 mmHg) improved surgical condition