Laparoscopy anesthesia: challenges for anaesthesiologist

Subcutaneous Emphysema

1. Extra peritoneal placement on Verres needle

2. Inadvertent extra peritoneal insufflations

Extensive subcutaneous emphysema may cause

• Respiratory impairment ,
• Pneumothorax,
• Pneumomediastinum

Subcutneous emphysema

Increase area of CO2 absorption

Hypercarbia and acidosis

Anesth Analg. 1993 Mar;76(3):622-6.

Pulmonary CO2 elimination during surgical procedures using intra- or extraperitoneal CO2 insufflation.

Mullett CE

Conclusion:

Management:

• Observation,O2
• Surgical incision
• Chest tube if

pneumothorax

CO2 diffusion into the body is more marked during extraperitoneal than during intraperitoneal CO2 insufflation

Hypercarbia (  ETCO2),

Hypoxia

High airway pressure,

CO2

Pneumoperitoneum

Inadequate ventilation

Inadeqate muscle relaxation

High IAP

Tachycardia

Pneumothorax

Hypertension

Reduce IAP

Hypercarbia

RR, Tidal Volume

Shift in position of tube

Decrase SPO2

FiO2, Apply PEEP

Bradycardia, VPC

Bronchospasm

Give proper relxation

More freqently than other surgeries.

• High risk patients we request surgeon to operating pressure on the lower side

Correction

Inadequate ventilation

Shift in position of tube

Reduce IAP

Respiratory

problems

How do you correct inadequate ventilation

V Q Mismatch

IPPV WITH VENTILATOR IS MUST TO PREVENT RESPIRATORY PROBLEMS

Have you ever felt laparoscopic anesthesia as hurdle race?

• Laparoscopy technique related physiological changes and complications

Physiological changes during laparoscopy

Physiological invasiveness – anesthetist and surgeon both should be aware of the physiological changes

Hypoxia

High airway pressure,

Hypercarbia (  ETCO2),

Always deflate the stomach with ryle’s tube before trocar insertion

Occurs because of

All emergency cardiac and respiratory drugs should be available inside the operation theatre before the starting of the surgery

CO2

Pneumoperitoneum

Always patient should pass urine just before entering the operation theatre ,if in doubt or for all prolong surgery pass urinary catheter

Inadeqate muscle relaxation

High IAP

We will understand how can we clear all this hurdle's effectively

Pneumothorax

1 Creation of Pneumoperitoneum

• Physiological changes of carbopneumoperitoneum and its implication

Reduce IAP

Shift in position of tube

Higher monitoring standard than routine surgery .

Monitoring of ETCO2 , airway pressure is must during surgery.

Our setup needs to be upgraded

Pneumoperitoneum detrimental changes are more at higher IAP (> 12 to 14)- try to keep it at lower side and at any given time if there is a problem- deflate the abdomen if possible

multiparamonitor with ETCO2

Bronchospasm

boyle’s app with hypoxia guard and in-build ventilator

2 CO2 insufflations and its

absorption leading to hypercarbia.

Halothane is contraindicated and sevoflurane / isoflurane / propofol are drug of choice for anesthesia

ventilator with airway pressure monitor

General anesthesia,

intubation and

ventilation with ventilator

is must to correct all respiratory physiological changes and hypercarbia.

Give proper relxation

use of

isoflurane, propofol sevoflurane

Correction

Inadequate ventilation

Infusion pumps

• IAP < 8 mm of Hg produce minimum or no changes

Shift in position of tube

Reduce IAP

• Challenges and its management
• Laparospecific complications

Flow of Lecture

• Higher the IAP higher are chances of complication .

> 14 mm of Hg increase the chance of complication

3 Positioning of patient

Respiratory

problems

How do you correct inadequate ventilation

V Q Mismatch

Special efforts should be made to avoid hypothermia

Thank You

IPPV WITH VENTILATOR IS MUST TO PREVENT RESPIRATORY PROBLEMS

Vigilance and team work is essential for safe and smooth outcome.

• Perioperative concerns

↓ Lung Volume,

↓ Compliance,

↑ Airway Resistance

• Intra abdominal pressure (IAP) of 12-14 mm of Hg is ideal for surgery

Summary

Carbon dioxide pneumoperitoneum, physiologic changes and anesthetic concerns:

Gobin Veekash MD ambulatory Surgery 16.2 July 2010

Physiological changes at 12-14 mm of Hg

1.Pneumoperitoneum

Metabolic acidosis

Respiratory acidosis

Hypoxia

Pulmonary problems

(pneumoperitoneum)

Increase in

HR,BP,SVR

&

Arrhythmias

sympathetic stimulation

Chui PT, Gin T, Oh TE. Anesthesia for laparoscopic general

surgery. Anesth Intensive Care. 1993;21(2):163–171.

• Intra Abdominal Pressure
• Duration of surgery.
• Capacity of clearance or Ventilation

ALL PREVIOUS CHANGES WERE DUE PRESSURE EFFECT OF GAS IN ABDOMINAL CAVITY. THIS ARE THE CHANGES DUE TO CO2 ABSORPTION IN TO THE BODY.

MOST OF CHANGES ARE SAME AS PRESSURE CHANGES AND IT MAKES IT IMPACT ALMOST DOUBLE MAKING PATIENT PRONE FOR ALL PHYSIOLOIGCAL CHANGES AND ITS PROBLEMS.

patients with compromised cardiopulmonary function and restricted CO2 clearance can develop severe hypercarbia despite aggressive hyperventilation

prolonged surgery under high IAP unless minute ventilation is increased.

Systemic absorption of gas from pneumoperitoneum is determined by factors such as solubility of the gas, IAP and duration of surgery.

-High IAP leads to external iliac, venacaval compression

HYPERCARBIA

CVS Changes

(pneumoperitoneum)

GI Physiology

Renal Physiology

(pneumoperitoneum)

increased

Airway resistance

- Head low position with knee rest which create popliteal vessels compression OR head up for upper abdominal surgery

• Hypoxia,
• Hypercarbia
• High airway pressure

Venous stasis in lower limb and calf vessels

Preload

After load

Anaesthesia. 1996 Aug;51(8):744-9.

Effects of carbon dioxide insufflation for laparoscopic cholecystectomy on the respiratory system.

Pelosi P

We found that abdominal carbon dioxide insufflation caused: a reduction in compliance of the respiratory system (both lung and chest wall components) and of functional residual capacity; a marked increase in the maximum resistance of the respiratory system (mainly due to increases in the viscoelastic properties of the lung and chest wall); no change in oxygenation, but an increase in the end-tidal carbon dioxide tension (which was correlated closely with the arterial carbon dioxide tension). These changes were not affected by the duration of anaesthesia.

Decrease

pulmonary compliance

Changes in vascular tone

Changes in gastric pressure

2

-Increase in SVR ,

- Caval compression

2.CO2 Insufflation & Absorption

Alteration of Venous Return,

- Caval compression

- Position influence

Decrease in lung volumes

(FRC, VC)

+

Higher insufflations rate can cause neutrophil clumping and activation of coagulation cascade

Decrease blood flow to liver and spleen

Should be given prophylaxis(LMWH) , precautions (pressure stockings)

J Clin Anesth. 2001 Aug;13(5):361-5.

Influence of pneumoperitoneum and patient positioning on respiratory system compliance.

Rauh R

2.Acta Anaesthesiol Scand. 1998 Mar;42(3):343-7.

Plasma catecholamines and haemodynamic changes during pneumoperitoneum.

Myre K1, Rostrup M, Buanes T, Stokland O

Increase in gastric stasis

Contractility

Increased intra abdominal pressure causes upward displacement of diaphragm and impairment of mobility

1. Surg Endosc. 1995 Feb;9(2):121-4.

The adverse hemodynamic effects of laparoscopic cholecystectomy.

McLaughlin JG1, Scheeres DE, Dean RJ, Bonnell BW.

as diaphragm is pushed upward, alveoli collapse and airway resistance increases and compliance decrease leads to difficulty in respiratory system - an we need to counteract this changes with additional efforts otherwise patient will develop hypoxia, hypercarbia, brochospasm

Influence of position

Decrease renal blood flow and increase vascular resistance

Deep Venous Thrombosis

Acta Anaesthesiol Scand. 1994 Apr;38(3):276-83.

Haemodynamic effects of pneumoperitoneum and the influence of posture during anesthesia for laparoscopic surgery. Odeberg S

1

preload - increase with iap <10 , decrease with iap>10 due to venacaval compression , same preload improve with head low but decrease with head up,

cardiac performance overall should remain unaltered as hr increase and BP decreases, afterload increase as svr increase-

overall in healthy normal young heart all changes are tolerated well but with slightest of derangement of heart function you are going to go introuble

so we must be sure about heart function before we venture in to laparoscopy

preload that is fluid coming back to heart will reduce if iap is high and ivc is compressed -it will increase if pressure is low and if we give extreme head low position

both case detrimental if heart condition is not optimal

after load increase there is pressure of abdominal aorta leading increase in peripheral vascular resistance

cardiac performance is also altered due to increase in hr and changes in cardiac output

overall patients will have increas hr , blood pressure and peripheral vascular resistance , alteration of venous return

Tachycardia, Hypertension, Strain

The adverse hemodynamic effects of anesthesia,

1.Acta Anaesthesiol Scand. 1995 Oct;39(7):949-55. trendelenberg position

2.Surg Endosc. 2000 Mar;14(3):272-7. Head up tilt

carbon dioxide pneumoperitoneum

during laparoscopic cholecystectomy.

Hirvonen EA et al

3.Neurol Res. 1999 Oct;21(7):658-60. changes in cerebral hemodynamics during laparoscopic cholecystectomy.

De Cosmo G et al

Decrease in UOP

Anesth Analg. 1997 Oct;85(4):886-91.

Splanchnic and renal deterioration during and after laparoscopic cholecystectomy: a comparison of the carbon dioxide pneumoperitoneum and the abdominal wall lift method.

Koivusalo AM1, Kellokumpu I, Ristkari S, Lindgren L

• Head low position

4.Middle East J Anesthesiol. 2002 Jun;16(5):521-8.Influence of the patient positioning on respiratory mechanics during pneumoperitoneum

Salihoglu Z1, etal

During surgery the patient is positioned so as to produce gravitational displacement of the abdominal viscera away from the surgical site.

4

• Exacerbate pulmonary effect of pneumoperitoneum

↓ FRC , VC

High risk for developing DVT are

• Old Age, Obese Pt ,
• Prolong Surgery,
• On OC Pills,
• Known C/O DVT, varicose Veins,
• Malignancy Etc.

• Increase venous return and cardiac output

1

Development of deep venous thrombosis,

Increase chances of pulmonary emobolism

• Congestion of head and neck
• Compromise cerebral perfusion and increase ICP
• Increase Intra ocular pressure

Implication of Carboperitoneum's alteration of physiology

3

• Head up position

• Improves the pulmonary function as it counteract the effect of pneumoperitoneum

• At the expense of cardiovascular changes as it ↓ the venous return (preload) and cardiac output

a hurdle race

2

• Increases the venous stasis and chances of DVT.

Tachycardia

Hypertension

Bradycardia, VPC

Challenges

Decrase SPO2

Anesthesia & Analgesia:July 1996 -

The Effect of Laparoscopic Cholecystectomy on Cardiovascular Function and Pulmonary Gas Exchange

Girardis, Massimo MD; Da

Why you have this challenges?

Hypercarbia

High Risk Patient Group For Laparoscopy

Hypothermia

Tachyarrhythmia's, HT, Brady arrhythmia,

Decrease Urine Output

• CVS

• Emergency surgery with uncontrolled bronchospasm should be avoided

• Patients can undergo plan laparoscopy surgery after careful preparation with bronchodilators

• Patients should always be prepared for open surgery if bronchospasm goes out of control

• Respiratory

Very common during laparoscopy surgery esp. with prolonged surgery,

• GI and Metabolic chalanges

Hypoxia , Hypercarbia,

high airway pressure

Evidence of venous stasis after abdominal insufflation for laparoscopic cholecystectomy. Beebe DS, etal Surg Gynecol Obstet. 1993 May;176(5):443-7. Pub Med PMID:8480266.

Lower-extremity venous stasis during laparoscopic cholecystectomy as assessed using color Doppler ultrasound. Ido K, etal Surg Endosc. 1995 Mar;9(3):310-3.

Pub Med PMID: 7597605

• Steep trendelenberg position

Surgery. 1994 Oct;116(4):733-9; discussion 739-41.

Pharmacologic intervention can reestablish baseline hemodynamic parameters during laparoscopy.

Feig BW1,

J Laparoendosc Adv Surg Tech A. 2003

Laparoscopic cholecystectomy for patients with chronic obstructive pulmonary disease.

Hsieh CH

Decrease UOP

Metabolic acidosis

Regurgitation , vomiting

• Ischemic Heart Diseases, Valvular Heart Disease

Limited cardiac reserve- May not tolerate changes in pre load and after load , contractility and other physiological changes

• Chest Disease

COPD , Asthmatic patients- Already has CO2 retention and high airway pressure

All physiological changes leads to various intra-operative problems which a knowledgeable and vigilant anesthetist should overcome

-Cool CO2 gas-

every 50 Liter of CO2 reduces temperature by 0.3° c

- Low ambient temp,

cool iv and

irrigation fluid

Surgical Endoscopy

July 1995, Volume 9, Issue 7, pp 791-796

Hypothermia induced by laparoscopic insufflation

J. R. Bessell

Am J Obstet Gynecol. 1997;

The role of irrigation in the development of hypothermia during laparoscopic surgery.

Moore SS et al

Management

-IV and irrigation fluid at body temperature

-Humidification of anesthesia gases with use of close circuit and soda lime

• Sickle Cell Disease

Erythrocytes May Sickle Easily because Of Acidosis

• Glaucoma

• High Intracranial Pressure-

How many of you have are doing it under spinal anesthesia?

if u search literature , there are now many report surfacing?

i will show you 2 supporting spinal anesthesia

First is lap chole under spinal 300 cases - they have opine it is feasible, reasonable success, very less post operative pain. shoulder tip pain and discomfort , which is reported very high in other studies not very high here, but in detail anlaysis gives you some points which are clearly not routinely practices- use of L1-L2 for spinal anesthesia, average surgica time around 4o mins,

no observation regarding respiratory parameters

Now there is one study also reported maintenance of proper respiratory parameters under spinal anesthesia in head low.

but again here IAP level is 8 cm of h20

very small study of 37 cases in very healthy patient

nearly all have some or other problems and degree of trendelenberg not clear,

when you review other literature common findings- only done on healthy , average weight patient

not on IAP 12-14 Which is routine for average surgeon and regular condition

almost all had shoulder tip pain and many reported very high incidence necessiting treatement with ketamine, propofol etc. ??

most of reported studies are for cholecytectomy where routinely we give GA for open surgery

Main advantages mainly post op pain and PONV only initial period not beyond 6 hrs

My gold standrd is still GA only for laparoscopy

How frequently you face these problems??

6. Few patient you still need to convert to GA.

5. Majority studies are for Cholecystectomy (open routinely done under GA) were head up position is given, but very few studies for pelvic surgery with head low position. Degree of trendelenberg not clear.

Carbon dioxide pneumoperitoneum, physiologic changes and anesthetic concerns Gobin Veekash MD ambulatory Surgery 16.2 July 2010

Use of N O

2

4. Immediate pain and PONV are better but not beyond 6 hrs.

Prevention and management of laparoscopic complication 3rd edition, Laparoscopic physiological perturbations: implication for at risk patients.C Michael Dunham, Amy e.Hutchinsion, Michael s. Kavic

J Anaesthesiol Clin Pharmacol. 2010 Oct-Dec;

Respiratory Changes During Spinal Anaesthesia for Gynaecological Laparoscopic Surgery

Raju N Pusapati, M Ravishankar

General anesthesia is currently choice of anesthetic technique for laparoscopic surgery

3. Other studies have given higher incidence of shoulder pain, requiring treatment with ketamin, propfol etc.

Surgery. 1994 Oct;116(4):733-9; discussion 739-41.

Pharmacologic intervention can reestablish baseline hemodynamic parameters during laparoscopy.

Feig BW1,

Tachycardia, SVT, Hypertension

2. IAP at 8 mm Hg. Required IAP of 12-14 - no studies ?

J Minim Access Surg. 2013 Apr-Jun; 9(2): 65–71

Laparoscopic cholecystectomy under spinal anaesthesia: A prospective, randomised study- 300 cases

Sangeeta Tiwari

1. Only very healthy patient with normal Lungs

CVS: Tachyarrhythmia's, HT

Disadvantages

• Intestinal distension
• Postoperative nausea vomiting
• Combustion hazard
• Can enlarge the size of air embolus
• Environmental concerns

Indian J Urol. 2008 Jan-Mar; 24(1): 126–127.PMCID: PMC2684234

Nitrous oxide during anesthesia for laparoscopic donor nephrectomy: Does it matter?

Pratipal Singh

R

x

4. Degree of Trendelenberg Position not clear

3. IAP 8 cm of H2O

2. All most all patient had some events.

The difference from conventional surgical and anesthesia technique:

1. All surgeries done at IAP - 8 mm Hg.

2. Spinal injection at L1- L2 level

3. Nearly 25 % had some intraoperative event which required interventions

4. Average surgical time was only 40 min.

1. Small No, of patient

Non pharmacological-

• Proper plane of the anesthesia
• Reduce the pressure
• Deflate the pneumo if critical tachycardia

Hence it is a safe alternative to general anaesthesia.

Taylor E, Feinstein R, White PF, Soper N. Anesthesia for laparoscopic

cholecystectomy. Is nitrous oxide contraindicated? Anesthesiology. 1992

Apr;76(4):541-3. PubMed PMID: 1550279.

CONCLUSION:

Laparoscopic cholecystectomy done under spinal anaesthesia as a routine anaesthesia of choice is feasible and safe.

Deflate the pneumo if critical tachycardia

Practical consideration

Advantages

• Excellent analgesic
• Various studies are inconclusive about PONV and usage of antiemetic usually eliminate this hazards
• Bowel distension varies from patients to patients and difficulty varies from surgeon to surgeon, blanket refusal not appropriate.

Post operatvie - drowsiness, PONV, shoulder tip pain less with abd wall lift

Reasons

• Hypercarbia

• Increase IAP

• Lighter plane of anesthesia

J Anaesthesiol Clin Pharmacol. 2010 Oct-Dec;

Respiratory Changes During Spinal Anaesthesia for Gynaecological Laparoscopic Surgery

Raju N Pusapati, M Ravishankar

Conclusion:

In a conscious patient undergoing laparoscopy with pneumoperitoneum, under spinal anaesthesia, the preserved inspiratory diaphragmatic activity maintains ventilation and, the gas exchange within physiological limits.

Br J Anaesth. 1995 Nov;75(5):567-72.

Conventional pneumoperitoneum compared with abdominal wall lift for laparoscopic cholecystectomy.

Lindgren L1, Koivusalo AM, Kellokumpu I.

J Minim Access Surg. 2013 Apr-Jun; 9(2): 65–71

Laparoscopic cholecystectomy under spinal anaesthesia: A prospective, randomised study- 300 cases

Sangeeta Tiwari

How many of you give anesthesia for laparoscopic surgery?

GENERAL ANAESTHESIA vs. SPINAL ANESTHESIA

Drugs

• Esmolol, diltiazem for tachycardia

• NTG for HT

Post operative pain relief

Ventilatory settings

• To prevent hypercarbia increase in MV with increase in Tidal volume &/or Respiratory Rate with keeping airway pressure < 30 cm of H2O .

Bradycardia, AV dissociation, VPB,VT, VF, ASYSTOLE

Reason for pain in laparoscopy

• Diffuse dull to severe aching abdominal pain due port’s incision
• Pain of surgical dissection
• Referred pain in shoulder from diaphragmatic irritation of CO2 insufflations
• Pain due to improper LIthotomy position or outstretched arm

• Controlled ventilation with good muscle relaxation with ventilator is must
• Use of SGA for laparoscopy is acceptable and effective alternative.

Criteria for Ventilator setting to Maintain

1. EtCO2 between 35-45 mm of Hg

2. SPO2 above 95 %

3. Airway Pressure < 30 cm of H2O

Prevention and management of laparoscopic complication 3rd edition, Laparoscopic physiological perturbations: implication for at risk patients.C Michael Dunham, Amy e.Hutchinsion, Michael s. Kavic

• Use of PEEP (5-10 cm of H2O ) or intermittent recruitment to prevent atleactasis and avoid hypoxia duriing surgery.

Aust N Z J Obstet Gynaecol. 1991 May;31(2):171-3.

Bradyarrhythmias and laparoscopy: a prospective study of heart rate changes with laparoscopy.

Myles PS.

Pressure control

Our setup needs to be upgraded

• Mode of ventilation- Pressure control vs Volme control.

• Pressure Control vs. Volume Control

Pneumoperitoneum detrimental changes are more at higher IAP (> 12 to 14)- try to keep it at lower side and at any given time if there is a problem- deflate the abdomen if possible

Multiparamonitor with ETCO2

• Expectation for faster recovery, early ambulation, early discharge ,need better post op. pain relief.

• Multimodal pain relief regime for complex surgery on ambulatory basis

Physiological invasiveness –

Anaesthesiologitist should be aware of the physiological changes

General anesthesia, intubation and ventilation with ventilator with airway pressure monitor is must to correct all respiratory physiological changes and hypercarbia.

boyle’s app with hypoxia guard and in-build ventilator

R

Can J Anaesth. 1993 Mar;40(3):206-10.

Ventilatory requirements during laparoscopic cholecystectomy.

Wahba RW1, Mamazza J

x

Higher monitoring standard than routine surgery .

Monitoring of ETCO2 , airway pressure is must during surgery.

All emergency cardiac and respiratory drugs should be available inside the operation theatre before the starting of the surgery

Evidence based postoperative pain relief management after laparoscopic colorectal surgery. G P Joshi et al. Colorectal Disease, Vol 15, Issue 2. Pages 1460155, Feb 2013.

Solutions in Brief

Halothane is contraindicated and sevoflurane / isoflurane / propofol are drug of choice for anesthesia

Bradycardia , ventricular arrhythmia’s

we report that increasing minute ventilation by 12-16% during laparoscopic cholecystectomy in a healthy population sample maintained PaCO2 at acceptable levels and that PETCO 2 monitoring should be used as an estimate of Paco2 with caution.

Special efforts should be made to avoid hypothermia

Infusion pumps

• Port site infilteration of LA

ventilator with airway pressure monitor

use of

isoflurane, propofol sevoflurane

Intraperitoneal Bupivacaine instillation for postoperative pain relief after laparoscopic cholecystectomy , Neerja Bhardwaj, et al Indian J Anaesth, 2002;46(1): 49-52

Vigilance and team work is essential for safe and smooth outcome.

• Intraperitoneal instillation of Bupivacaine

Hyperventilation, PEEP, Recruitment maneuver, PCV

Reasons

• Hypercarbia

• Vagal stimulation due to pneumoperitoneum

• Halothane

• CO2 embolism

Non pharmacological-

• Reduce the pressure
• Deflate the pneumo if critical bradycardia or ventricular arrhythmia

• Avoid halothane
• Start resuscitation
• Defibrillation

Deflate the pneumo if critical bradycardia or ventricular arrhythmia

Drugs

• Atropine
• Xylocard
• Anti arrhythmic drugs

ANESTHESIA DRUGS

Summarise:

• NTG
• ESMOLOL
• ATROPIN
• XYLOCARD
• DILTIAZME

Availability of all emergency cardiac drug is essential before starting of lap surgery

You may require to use them to correct physiological changes

All short acting drugs are preferred .

• Antiemetic and Analgesic is essential.

• Good muscle relaxation is essential for lap surgery.

Anesthetist has challenge

to correct physiological abnormality

created by surgical technique

other than disease.

Contact: airway@greenashram.org

amit20668@gmail.com

apekshpatwa@gmail.com

Thanks

Halothane

Observership for Advance airway management for 15 days

Goraj

Twice in year: January / July

• Halothane is not preffered

6 Month Fellowship for the Advance airway management

at Goraj

• It sensitize myocardium for arrhythmias in presence of CO2.

EXTRA WORK

Fiberoptic and Videoscopic intubation training course

January and July.

Should not be used even for minor or smaller procedure as sensitization is not time based

AIDiAA & Muni Seva Ashram Goraj

Laparoscopic surgery is

Anatomically minimally invasive

but

physiologically equally or more invasive

Knowledge of problems and vigilance are key factors to overcome challenges of laparoscopic anestheis

Anesthesiologist & surgeon both should know physiological implications

Both should complement each other, more than any other surgery

which may lead to disastrous consequences

Dr Amit Shah

Dr Apeksh Patwa

Challenges For

Anaesthesiologists

Laparoscopic Surgeries:

ALL IS NOT WELL

Prevention and management of laparoscopic complication 3rd edition, Laparoscopic physiological perturbations: implication for at risk patients.C Michael Dunham, Amy e.Hutchinsion, Michael s. Kavic

Paediatric Laparoscopy:

Respiratory problems:

Key Points to Remember :

Reasons

Corrections:

• Always deflate the stomach with ryle’s tube before trocar insertion

Anesthesia Concerns:

Laparoscopic Surgery in Children - Anaesthetic Considerations.

Aliya Ahmed

( Department of Anaesthesia, Aga Khan University Hospital, Karachi. )

• Preoperative concerns
• High risk for anesthesia- cardiac, respiratory

Acta Anaesthesiol Sin. 1995 Mar;33(1):1-6.

The physiological effect of CO2 pneumoperitoneum in pediatric laparoscopy.

Hsing CH

The changes of PETCO2 during laparoscopy

did not influence the hemodynamic stability in our study.

The younger children give

a faster reaction time of PETCO2 change after CO2 insufflation than do the older children

• Rull out Complications.

• Correct ETT position

• Increase Minute ventilation

• Pneumoperitoneum detrimental changes are more at higher IAP (> 12 to 14)- try to keep it at lower side and

at any given time if there is a problem- deflate the abdomen .

• Hypercarbia
• High airway pressure
• Hypoxia

• Increase FiO2, Apply PEEP

• Reduce IAP, Improve relexation

• Other complications :
• Pneumothorax, bronchospasm etc

• Shift in position of ETT

• Inadequate relaxation

It has been recommended that the IAP produced by pneumoperitoneum

should be limited to 5-10mmHg in toddlers and infants and to about 10-12mmHg in older children

• Inadequate ventilation

• High IAP

• General anesthesia, ventilation with ventilator is must to correct all respiratory physiological changes and hypercarbia.

• Patient with lower cardiac and pulmonary reserve require special preoperative investigation and preparation.

Solutions in Brief

• Halothane is contraindicated .

• Intraoperative-
• Positioning
• Monitoring
• Ventilation
• Drugs
• Halothane
• N2O

↓ Lung Volume, ↓ Compliance, ↑ Airway Resistance

Paediatr Anaesth. 2003 Jan;13(1):18-25.

Haemodynamic changes during low-pressure carbon dioxide pneumoperitoneum in young children.

De Waal EE

We conclude that low-pressure CO2 pneumoperitoneum (with IAPs not exceeding 5 mmHg) for laparoscopic fundoplication in infants and children does not decrease their cardiac index.

• Higher monitoring standard than routine surgery . Monitoring of ETCO2 , airway pressure is must during surgery

Ventilation is usually needed to be

increased by 15-30% during the procedure to compensate for the extra load of CO2 and

PEEP may be required to counter the effects of increased IAP on FRC.

• Pneumothorax, CO2 embolism, Subcutaneous emphysema are rare but serious complications. Vigilance is key to detect this problems early.

• Post operative care
• Pain management

• GA vs Regional

• Laparoscopy in paediatric patients

o

Ghomi A, Kramer C, Askari R, Chavan NR, Einarsson JI. Trendelenburg position in gynecologic robotic surgery. J Minim Invasive Gynecol. 2012;19(4):485-489 -

• Surgeons were blinded to degree of tilt
• 15 sufficient for effective visualization

Monitoring

High Risk cases:

• ECG, NBP, SPO2, RR, Temp.

/

>

• Chest Disease

COPD , Asthmatic patients-

Preoperative Cardiac Evaluation

Capnography is the monitoring of the respiratory carbon dioxide (CO2) concentration as a time-concentration curve. It is a direct monitor of the inhaled and exhaled concentration of CO2, and a indirect monitor of the CO2 in a patient’s blood.

Already has CO2 retention and high airway pressure

30-40

o

• Oliguria during laparoscopic surgery. Chang DT, Kirsch AJ, Sawczuk IS JEndourol. 1994 Oct;8(5):349-52. Pub Med PMID: 7858621.
• Splanchnic microcirculatory changes during CO2 laparoscopy. Schilling MK, J Am Coll Surg. 1997Apr;184(4):378-82
• Laparoscopic insufflation of theabdomen reduces portal venous flow. Jakimowicz J,.Surg Endosc. 1998 Feb;12(2):129-32. Pub Med PMID: 9479726

Trendelenberg

How much ?

o

• Ischemic Heart Diseases,

Valvular Heart Disease

• ETCO2

Any patient with any

• history of chest pain
• breathlessness ,
• pedal edema,
• ECG changes,
• presence of HT or DM

should undergo further testing

Limited cardiac reserve

• Patient slippage, injuries due to restrain
• Facial trauma, Corneal abrasion
• Facial , eyelid edema
• Increase ICP, IOP
• Endobronchial intubation

Potential problems

• Airway pressure

Severe uncorrected hypovolaemia, and patients with known right-to-left cardiac shunts or patent foramen ovale are considered contraindication to the laparoscopic surgery

Prevention and management of laparoscopic complication 3rd edition, Laparoscopic physiologica perturbations: implication for at risk patients.C Michael Dunham, Amy e.Hutchinsion, Michael s. Kavic

• High risk cases:

ABP, CVP, PCWP, TEE etc.

• Stress Echo (DSE) or Plain (2D) Echo

• Stress Echo (DSE) or TMT over plain Echo for IHD.

Prevention and management of laparoscopic complication 3rd edition, Laparoscopic physiologica perturbations: implication for at risk patients.C Michael Dunham, Amy e.Hutchinsion, Michael s. Kavic

• Sickle cell disease

• Plain Echocardiography for valvular heart disease

Surg Gynecol Obstet. 1993 Jun;176(6):548-54.

Laparoscopy in high-risk cardiac patients.

Safran D1, Sgambati S, Orlando R 3rd.

• High Intra cranial and ocular pressure

Anesthesia for laparoscopic surgery, Paul Hayden, Sarah Cowman BJA: CEACCP Volume 11, Issue 5Pp. 177-180

Gastric stasis

• Proved ischemic heart disease should be taken only in best of laparoscopic and anesthesia, recovery setup with ICU backup and explanation to patients

The SAGES Manual of Perioperative care in minimally invasive surgery. Whelan, R.L. etal 2006, XXIII< 491p. 106 illus., Soft cover. ISBN: 978-0-387-23686-5

Pneumothorax

Need to change NBM protocol ?

More problems at recovery

GI,RENAL & METABOLIC problems

Pneumoperitoneum

Insufflated CO2 tracking into thorax through

-Tear in visceral peritoneum,

• Regurgitation and vomiting-

High esophageal sphincter tone due to pneumoperitoneum

• Metabolic acidosis-

High IAP reduces blood lactate clearance from liver

-Breach of parietal pleura during dissection

around esophagus

• Less UOP during surgery –

Concern in prolong surgery

-Through congenital defect in diaphragm

• Verres needle or port injury
• Embolism- CO2 / DVT
• Pneumothorax
• Subcutaneous emphysema
• Hypothermia

Diagnosis

- ventilator shows high airway pressure

- ↓ SPO2

- ↓ air entry on one side

- ↓ BP

Anaesthesia and Intensive Care November 1, 2011

Surgical tension pneumothorax during laparoscopic repair of massive hiatus hernia: a different situation requiring different management

Philips S. et al

• Verres needle or port injury
• Embolism- CO2 / DVT
• Pneumothorax

Laprospecific Challenges

Management

-Deflate CO2 ,

J Clin Diagn Res. Apr 2014; 8(4):

Laparoscopy-Pneumothorax and Ocular Emphysema, A Rare Complication-A Case Report

-Many cases resolve spontaneously,

-Only large pneumothorax requires ICD

JoumalofMedicalCollegeChandigarh, 2011, Vol. 1; No.1

Case report: Pneumothorax during laparoscopy: one more reminder

Nidhi Bhati et al

RULL OUT PNEUMOTHORAX

WHEN EVER VENTILATOR SHOWS SUDDEN HIGH AIRWAY PRESSURE

• A Chakraborty, G Kumar, P Bhattacharya. Gastric Distension During Laparoscopic Cholecystectomy: Comparison between ETT and PLMA. The Internet Journal of Anesthesiology. 2006 Volume 13 Number 1.
• Anesthesia for laparoscopic surgery, Paul Hayden, Sarah Cowman BJA: CEACCP Volume 11, Issue 5Pp. 177-180

CO2 Embolism

• Potentially fatal
• May be caused by direct vascular puncture by Verres needle and gas insufflation

Manifestations and consequences

• Bradyarrhythmia's
• Hypotension,
• Pulmonary edema,
• Right ventricular failure,
• Paradoxical emboli,
• Cardiac arrest

PRECAUTION BY ANESTHESIOLOGIST

massive hemorrhage ,

gas embolization.

• Injury to major vessels can lead to

VERRES NEEDLE OR PORT INJURY

• Laceration of viscera-

visceral injury may manifest later as sepsis

Gas embolism was observed in all patients undergoing total laparoscopic hysterectomy, and 37.5% of patients had grades higher than III No patient in this study showed hemodynamic instability or electrocardiogram changes at the time of venous air embolism (VAE) occurrence.

Venous air embolism during total laparoscopic hysterectomy: comparison to total abdominal hysterectomy.

Kim CS, Kim JY, Kwon JY, Choi SH, Na S, An J, Kim KJ

Anesthesiology. 2009 Jul; 111(1):50-4.

Consequences depend on

• rate,
• amount and nature of gas,
• how early you detect it

How to detect CO2 Embolism

Yonsei Med J. May 1, 2012; 53(3): 459–466.

Carbon Dioxide Embolism during Laparoscopic Surgery

Eun Young Park

Management:

• Stop CO2 , Stop N2O
• 100% oxygen
• Extreme head low
• Right up position
• Call for help
• CPR
• Vasopressor
• Direct Aspiration
• CVP cannulation and removal of emboli

Now many abdominal surgeries for pediatric is also perfomed through laparoscopy. various evidence clearly says- pediatric patient react