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Patcha Chatchawarat,MD.
(RESIDENT-1)
Patients history and PE Factors risk of pulmonary complications Investigation Specific information Additional procedure Premedicaiton Three major forces alter the pt.s physiology
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?
laparoscopic procedure itself Age:- esp. age>70 years Smoking/COPD Obesity Overdehydration
Anesthesia 1995;50:286-289
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
Specific information
general
complication
Laparoscopy Anesthesia
emergency
Additional procedure
Diet
Pre-op
Premedicaiton
Anxiolytic NSAIDs Clonidine
& dexmedetomidine the intra-op stress response and improve hemodynamic stability
alter the
esp.Trendelenburg
PATIENT MONITORING
Standrad monitor
PATIENT MONITORING
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
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
(head
Gynecology Urology
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
minimal change
VR & CO CVP,PCWP,SVR,and HR
CVS disease
acute HF
PATIENT POSITIONING
Nerve injury
esp.
extremity neuropathy
Lower
CHOICES OF ANESTHESIA
resident 3
ANESTHETIC TECHNIQUES
Local anesthesia
cooperation&relax IV
pt.
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
GENERAL ANESTHESIA
F3 esp.hypercarbia&hypoxia N2O----controversy
An antiemetic drugs
Droperidol,5-HT3
antagonist
A vagolytic drug
esp.
TIVA--propofol--awareness(Bis)
Resident 1
HYPERCARBIA
HYPERCARBIA
Factors in laparoscopy
Patients
with sig.cardiopulm. dis. Intraabdominal pressure>15mmHg Presence of subcutaneous emphysema Retroperitoneal rather than intraperitoneal approach Long duration
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
The
cosmetic Non muscle-splitting incisions blood loss Less post-op pain and ileus Shorter hospitalization and convalescence Lower cost
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
Gynecology
Tubal surgery
sterilization,ectopic preg.
endometriosis
INDICATIONS
General surgery
Cholecystectomy Hermia repair Antireflux procedure Splenectomy, appendectomy, bowel sx. Various upper and lower abdominal procedures
anterior approach
Autopsy
CONTRADICATIONS
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
large intraabdominal mass Tumor of the abdominal wall Hypovolemic shock A beta-blocked pt. Patient refusal
CONTRADICATIONS
Relative contraindication
VP
The Advantages
Nonflammable Not
support combusion Readily diffuses across membranes Rapidly removed in the lungs Highly soluble(buffering in RBCs)
H2O + CO2
H+ +HCO3-
Small
The disadvantages
Not
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
LAPAROSCOPIC SURGERY
Pneumoperitoneum
Patient positioning
Trendelenberg
Carbon dioxide
A
PNEUMOPERITONEUM
Abdominal distention
all 4 quadrants
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
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)
Increased in PaCO2
emphysema
Capnothorax CO2
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
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
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
RISK OF ASPIRATION
Hemodynamic promblems
Hemodynamic promblems
In healthy patients
significant
Hemodynamic promblems
Regional hemodynamics
Thromboembolic
complications
function
Hemodynamic promblems
Regional hemodynamics
Splanchnic
blood flow
If maintain normocarbia
not halmful
IOP
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
sudden streching of the peritoneum light anesthesia Pt. with beta-blockers electrocoagulation of the follopian tube Treatment easily and quickly reversible
Stress response Postoperative Pain Pulmonary Dysfunction Postoperative Neusea and Vomitting (PONV) ( Miller RD,Anesthesia,5th ed.)
Stress response
Acute phase reaction ( CRP& interleukin-6) Metabolic response Ileus & fasting endocrine response Adrenocortical stimulation Combined with EDB decrease Pre-op Alpha2-agonists
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
Treatment
Postoperative Pain
Treatment
Topical anesthesia
Local
Pre-op NSAIDs
pain&opioid use
Pulmonary Dysfunction
Pulmonary function
less severe quicker recovery slower in obese, smokers,and COPD than healthy pt. remain impaired not improved
Diaphragmatic Function
high incidence (40-75%) delay discharge in OPD cases intra-op opioid use propofol anesthsia(TIVA) N2O??
stomach Intra-op IV droperidol, odansetron and transdermal scopolamine intra-op opioid use
Postoperative management
O2 administration
early post-op
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