laparascopy ppok dr yu

8/18/2019 Laparascopy PPOK Dr YU

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Anesthetic considerations in the patients ofchronic obstructive pulmonary disease undergoing

laparoscopic surgeries


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INTRODUCTION

minimally invasive endoscopic surgery

• its benets in the form of diminishedpain

• no cosmetic disgurement

• satisfactory therapeutic results as

ell as !uic"er resumption of normalactivities accelerated


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#AT$O#$%&IO'O(% O) C$RONICO*&TRUCTI+, #U'-ONAR% DI&,A&,

• 'imitation of e.piratory air/o It is because ofthe combination of small airay in/ammation andparenchymal destruction

• anatomical lesions contribute to air/o limitation0including the loss of lung elastic recoil andbrosis and narroing of small airays0 both ofhich are li"ely to cause .ed air/o limitation

• +12 mismatch decreased gas transfer and

alveolar hypoventilation ultimately leads torespiratory failure


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DIA(NO&I& ANDA&&,&&-,NT

• Air/o limitation should be assessedaccording to the reduction in forcede.piratory volume in 3 s 4),+35

#AT$O#$%&IO'O(ICA' ,)),CT&


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#AT$O#$%&IO'O(ICA' ,)),CT&DURIN(

'A#ARO&CO#%

• In physiological e6ects of pneumoperitoneum0carbon dio.ide is shon to be a6ected by raisingthe intra7abdominal pressure 4IA#5 above thevenous pressure hich prevents CO8resorption

leading to hypercapnia

• Respiratory e6ects include the changes inpulmonary function during the laparoscopicsurgery in the form of a reduction in lung

volumes0 decrease in pulmonary compliance andincrease in pea" air/o pressure


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• Increased IA# shifts the diaphragm cephalad andreduces diaphragmatic e.cursion0 resulting in theearly closure of smaller airays0 leading tointraoperative atelectasis ith a decrease in

functional residual capacity

• the upard displacement of diaphragm leads tothe preferential ventilation of nondependent partsof lungs0 hich results in ventilation7perfusion

4+125 mismatch ith a higher degree ofintrapulmonary shunting


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• Cardiovascular changes depend on the interaction ofseveral factors including patient positioning0neurohumoral response and the patient factors suchas cardiorespiratory status0 and intravascular volume

• CO8pneumoperitoneum is associated ith theincreased preload and afterload in the patientsundergoing 'C

• It also decreases heart performance 4fractional

shortening5 but does not a6ect cardiac output• At IA# levels 93: mm$g0 the venous return

decreases leading to decreased cardiac output andhypotension


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• *radyarrhythmias are attributed to vagalstimulation caused by insertion of the needle orthe trocar0 peritoneal stretch0 or carbon dio.ideemboli;ation

• These may induce cardiovascular collapseduring laparoscopy even in the healthy patients

• Increased concentrations of CO8 and

catecholamines can create tachyarrhythmias


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• Increases in IA#0 cardiovascular responsesto peritoneal insu=ation0 changes in thepatient positioning and alterations in CO8

concentration can alter intracranialpressure and cerebral perfusion

• #neumoperitoneum reduces renal corticaland medullary blood /o ith an

associated reduction in glomerularltration rate0 urinary output andcreatinine clearance


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• The increase in IA# reduces thefemoral venous blood /o<

• This is due to the increased pressureon the inferior vena cava and iliacveins0 hich reduces venous blood/o in the loer e.tremities<

• It has also been shon to reduce theportal blood /o0 hich may lead totransient elevation of liver en;ymes


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AN,&T$,TIC -ANA(,-,NT

#reoperative evaluation

• A detailed history is essential for the clinical assessment ofCO#D severity and should focus on e.ercise tolerance

• routine preoperative blood tests

• electrocardiogram to loo" for any evidence of right7sidedheart disease or concomitant ischemic heart disease

• &pirometry is useful to conrm the diagnosis and to assessthe severity of CO#D

• A baseline arterial blood gas measurement may be useful

in predicting high7ris" patients0 ith both #aCO8 9 : "#aand #aO8 ? @ "#a predicting a orse outcome


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• Nutritional status should be routinelyassessed0 as patients ith both high andlo body mass inde. have increased ris"<

• #oor nutritional status ith a serumalbumin level ?: mg1' is a strongpredictor of postoperative pulmonarycomplications

• -a.imum benet is obtained if smo"ing isstopped at least B ee"s before surgeryith some studies


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• All patients ith CO#D re!uire a detailedpreoperative e.amination0 as decreasedbreath sounds0 prolonged e.piration0 hee;e0

and rhonchi are predictive of postoperativepulmonary complications

• &igns of active respiratory infection such aspyre.ia0 purulent sputum0 orsening cough0

or dyspnea should be sought0 and if identied0surgery should if possible0 are postponed andappropriate treatment instituted


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(eneral anesthesia

• The combined e6ects of the supineposition0 (A and thoracic1abdominalincision produce an immediate decline in

lung volumes ith atelectasis formation inthe most dependent parts of the lung

• the residual neuromuscular bloc"adepersisting after anesthesia emergence has

been incriminated in decient coughingdepressed hypo.ic ventilatory drive andsilent inhalation of gastric contents


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• Upper airay instrumentation 4e


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• #lacement of an arterial catheter shouldbe considered for both beat7to7beat bloodpressure monitoring and for repeated

blood gas analysis• The patients in maEor surgeries ith

severe CO#D and hypo.ia0 continuouspositive airay pressure during induction

may be used to improve the eFcacy ofpreo.ygenation and to reduce thedevelopment of atelectasis


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-echanical ventilation

• 'imited e.piratory /o rate because of airaynarroing results in the ne.t inhalation occurring beforethe e.piration of the previous breath is complete0 andleads to breath stac"ing or air trapping and the

development of intrinsic positive end7e.piratorypressure 4#,,#i5

• The elevation of intrathoracic pressure results indecreased systemic venous return and may betransmitted to the pulmonary artery0 raising pulmonary

vascular resistance and leading to right heart strain• Other potential harmful e6ects of air trapping include

pulmonary barotraumas or volutrauma0 hypercapnia0and acidosis


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Ghen considering ays to reduce the harmful e6ects of airtrapping0 there are three approaches to considerH

• Alloing more time for e.halation


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e.tubation

• The neuromuscular bloc"ing agent should be fullyreversed0 and the patient should be "ept arm0ell o.ygenated ith a #aCO8close to the normalpreoperative value for the patient

• #eri7e.tubation bronchodilator treatment may behelpful

• noninvasive ventilation may reduce the or" ofbreathing and air trapping

• $ypoventilation as a result of residual anesthesia or• opioids should be avoided as this may lead to

hypercarbia and hypo.ia


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Regional anesthesia

• Respiratory function is not a6ected by giving spinaland epidural anesthesia at lumbar level0 e.cept inmorbidly obese patients here the neura.ialbloc"ade has been shon to produce a 8J8:K fall

in e.piratory functional volume 4),+30 forced vitalcapacity5 and that may interfere ith the ability tocough and to clear bronchial secretions as a resultof bloc"ing the abdominal all muscles

•

limiting factor for use of spinal anesthesia inlaparoscopy is patientLs discomfort ithpneumoperitoneum and the associated shouldertip pain


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#O&TO#,RATI+,-ANA(,-,NT

• #rophyla.is against the developmentof postoperative pulmonarycomplications is based on

maintaining ade!uate lung volumeespecially )RC and facilitating ane6ective cough


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ANA'(,&IA

• ,6ective analgesia is a signicantdeterminant of postoperative pulmonaryfunction

•Regional anesthetic techni!ues andpatient7controlled rather than on demanddrug regimen are gaining attention inmodern analgesic strategies

• The e6ectiveness of pain control can befurther increased by the combination ofdi6erent analgesic agents


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CONC'U&ION

laparascopy ppok dr yu

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