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Anesthesie voor Abdominale Heelkunde Specifieke deeldomeinen M. Verhaegen 12-10-2012

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Page 1: Verhaegen - Anesthesie abdominale heelkunde - uzleuven.be - Anesthesie... · Geselecteerde Topics 1. Anesthesie voor abdominale heelkunde: Algemene aandachtspunten – Rapid sequence

Anesthesie voor Abdominale Heelkunde

Specifieke deeldomeinenM. Verhaegen12-10-2012

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Topics

1. Anesthesie voor abdominale heelkunde: Algemene aandachtspunten– Preoperatieve aandachtspunten– Anesthesietechniek– Intraoperatieve aandachtspunten tijdens een algemene anesthesie voor

abdominale heelkunde– Postoperatieve aandachtspunten

2. Laparoscopie met een CO 2-pneumoperitoneum– Insufflation gas– Pathofysiologische effecten– Verwikkelingen– Contra-indicaties– Anesthesie: aandachtspunten

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Geselecteerde Topics

1. Anesthesie voor abdominale heelkunde: Algemeneaandachtspunten– Rapid sequence induction

2. Laparoscopie met een CO 2-pneumoperitoneum– Insufflation gas– Pathofysiologische effecten– Verwikkelingen– Contra-indicaties– Anesthesie: aandachtspunten

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Textbook

Miller’s Anesthesia 7th editionRonald D. Miller

Anesthesia for laparoscopic surgery.Jean L. JorisVol. 2: Chapter 68 (p. 2185 – 2202)

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1. ALGEMENE AANDACHTSPUNTENANESTHESIE VOOR ABDOMINALE HEELKUNDE

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Preoperative Attention Points

• Preoperative evaluation– Les “Pre-operatieve screening en medicamenteuze voorbereiding”

(Prof. E. Vandermeulen)

• Assessment of intravascular volume status– Les “Vochtbeleid: krystalloïden – colloïden”

• Diagnosis of electrolyte or acid-base disturbances– Gastrointestinal fluid losses – Sepsis

• Hepatobiliary pathology: (severe) hepatic dysfunct ion is possible

• Assess risk of pulmonary aspiration of gastric cont ents

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Risk Factors for Pulmonary Aspiration of Gastric Contents (1)

• Emergent surgery and npo < 6 hrs or for clear liqui ds < 2 hrs• Emergent surgery following acute trauma• Risk of increased intragastric-esophageal pressure gradient

– Gastric outlet obstruction– Delayed gastric emptying (mechanical, diabetes mellitus)– Bowel obstruction– Paralytic ileus– Pregnancy > 12 weeks– Morbid obesity– Excessive ascites

• Impaired protective reflexes• Severe gastro-esophageal reflux disease

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Risk Factors for Pulmonary Aspiration of Gastric Contents (2)

• Emergent surgery and npo < 6 hrs or for clear liqui ds < 2 hrs• Emergent surgery following acute trauma• Risk of increased intragastric-esophageal pressure gradient• Impaired protective reflexes

– Parkinson’s disease– Neuromuscular disease

• Severe gastro-esophageal reflux disease���� Assess the need for a rapid sequence intubation (R SI)

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“Seven P’s” of RSI in Adults

1. Preparation2. Preoxygenation3. Pretreatment4. Paralysis and induction5. Protection and positioning6. Placement with proof7. Postintubation management

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“Seven P’s”: 1. Preparation (1)

• Assessment of the patient / airway– Anticipated difficult intubation: contraindication for RSI � awake

fiberoptic intubation?– Other contra-indications?

• E.g. allergy to rapid onset muscle relaxants

• Patient installation– Intravenous line– Monitoring

• ECG, pulse oximetry, blood pressure monitoring in place• Capnometry/-graphy available and ready to use

– Optimal positioning for intubation

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“Seven P’s”: 1. Preparation (2)

• Equipment– Endotracheal tube(s) of appropriate size, cuff free of leaks– Stylet (+/- placed in the tube)– Laryngoscope

• Tested• Different blades should be readily available

– Suction device, checked– Oral airway

• Drugs – Selection of induction and neuromuscular blocking agents– Determination of the doses– Drawn up in labeled syringes

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“Seven P’s”: 2. Preoxygenation

• Goal: to increase the apnea period with an O 2 saturation > 90% and avoid mask ventilation before intubation– Increasing oxyhemoglobin saturation– Denitrogenation: replacing nitrogen with oxygen in the lungs→ Increasing oxygen stores in lungs, blood and tissues

• Longer periods of apnea are tolerated without desaturation• Time to desaturation, even after preoxygenation, depends on patient

characteristics and clinical situation

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Preoxygenation prolongs the period to desaturation inparalyzed patients.

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“Seven P’s”: 2. Preoxygenation

• Goal: to increase the apnea period with an O 2 saturation > 90% and avoid mask ventilation before intubation– Increasing oxyhemoglobin saturation– Denitrogenation: replacing nitrogen with oxygen in the lungs→ Increasing oxygen stores in lungs, blood and tissues

• Longer periods of apnea are tolerated without desaturation• Time to desaturation, even after preoxygenation, depends on patient

characteristics and clinical situation

• Techniques– Technique of choice: 100 % oxygen by face mask during 5 minutes– Eight vital capacity breaths (maximal breaths) during 100 % oxygen

administration

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“Seven P’s”: 3. Pretreatment

• Goal: prevention of potentially adverse consequenc es of the physiologic responses to RSI

• Drugs used for pretreatment vary with clinical circ umstances. – Opioid

• Fentanyl, sufentanil• To blunt increases in heart rate and blood pressure during

laryngoscopy and intubation– Lidocaine

• 1.5 mg/kg iv 2-3 min before intubation • Suppression of cough reflex and attenuation of increased airway

resistance following intubation?• Attenuation of ICP rise upon intubation in patients at risk of

adverse effects of an increase in ICP

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“Seven P’s”: 4. Paralysis and Induction (1)

Goal: almost simultaneous, rapid induction and par alysis– Selection of agents (clinical situation)– Precalculated doses adequate to provide prompt loss of

consciousness and muscle relaxation (no titration)– Intubation 45-60 sec after administration of the neuromuscular

blocking agent

1. Induction: Rapidly acting intravenous induction agent– Propofol (1.5 – 3 mg/kg)

• Bronchodilation• Hypotension (reduction of cerebral perfusion pressure)

– Etomidate (0.3 mg/kg)• Hemodynamic stability• Suppression of adrenal cortisol production

– (Other: ketamine, midazolam)

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“Seven P’s”: 4. Paralysis and Induction (2)

2. Paralysis: Rapidly acting neuromuscular blocking agent immediately following the induction agent– Depolarizing NMBA: Succinylcholine (1-1.5 mg/kg)

• Rapid onset (45-60 sec), short half-life (6-10 min)• Rise in serum K+

• Contraindications– Significant (acute) hyperkalemia (ECG changes)– Personal or family history of malignant hyperthermia– Rhabdomyolysis– Acetylcholine receptor upregulation

» Denervating diseases» Myopathies» Prolonged total body immobilization» Extensive burn injuries ≥ 72 hrs old» Crush injuries ≥ 72 hrs old

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“Seven P’s”: 4. Paralysis and Induction (3)

2. Paralysis: Rapidly acting neuromuscular blocking agent immediately following the induction agent– Non-depolarizing NMBA: Rocuronium (0.9-1.3 mg/kg)

• Rapid onset (45-60 sec)• Longer duration of action than succinylcholine

– Duration of action of approximately 60 min after 1 mg/kg (may be much longer in older patients)

– Reversal is possible » Neostigmine» Suggamadex

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“Seven P’s”: 5. Protection and Positioning

Protection of the airway against aspiration of gast ric contents prior to intubation• Avoid mask ventilation

– Preoxygenation– O2-saturation < 90 % � mask ventilation with cricoid pressure

• Cricoid pressure (Sellick’s maneuver)– Prevention of passive regurgitation by occlusion of the esophagus– Effectiveness has been questioned

• Lateral displacement of esophagus

– Risks • May worsen visualization • Laryngeal obstruction with difficulty to pass the endotracheal tube• Esophageal rupture• Laryngeal trauma• Displacement of unstable cervical spine

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Sellick’s Maneuver (Cricoid Pressure)

• Applied by an assistant immediately following induc tion• Downward pressure on cricoid cartilage using thumb a nd

index finger– Avoid exerting pressure on the thyroid cartilage

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Sellick’s Maneuver (Cricoid Pressure)

• Applied by an assistant immediately following induc tion• Downward pressure on cricoid cartilage using thumb a nd

index finger– Avoid exerting pressure on thyroid cartilage– Pressure of 30 N– Release only after endotracheal tube placement has been confirmed

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“Seven P’s”: 6. Placement with Proof

• Laryngoscopy after sufficient muscle relaxation has been achieved (45-60 sec after NMBA administration)

• Placement of endotracheal tube (+/- stylet)• Confirmation of endotracheal tube placement

– End-tidal CO2-measurement– Auscultation over both sides of the chest and the stomach– (Visualization of the endotracheal tube between the vocal cords)– (Misting of the tube with ventilation)

• Check the depth of the tube– Auscultation is equal over both lungs

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“Seven P’s”: 7. Postintubation Management

• Secure the properly placed endotracheal tube• Start mechanical ventilation

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Anesthesia Technique

• Selection criteria for anesthesia technique– Surgical procedure– Contra-indications for a specific technique– Patient preference / objection

→ Neuraxial anesthesia→ General anesthesia +/- epidural anesthesia

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Perioperative Attention Points during General Anesthesia for Abdominal Surgery

• Monitoring• Induction of general anesthesia• Temperature• Fluid management• Muscle relaxation and neuromuscular monitoring

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Abdominal Surgery: Postoperative Attention Points

• Postoperative analgesia• Thrombosis prophylaxis• Prevention of stress ulcers• Postoperative nausea and vomiting• Postoperative continuation of preoperative medicati on

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2. LAPAROSCOPIE MET CO 2-PNEUMOPERITONEUMANESTHESIE VOOR ABDOMINALE HEELKUNDE

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Anesthesia for Laparoscopic Surgery with CO2-Pneumoperitoneum: Topics

• Insufflation gas• Pathophysiology• Complications• Contraindications• Anesthesia

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Laparoscopic Procedures for Gastrointesinal Surgery

• Diagnostic surgery• Cholecystectomy• Nissen fundiplication• Bowel surgery• Gastrectomy• Bariatric surgery• Pyloromyotomy

• Pancreatic surgery (Whipple)

• Partial hepatectomy• Splenectomy• Lymphadenectomy• Inguinal hernia• Appendectomy• …

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Laparoscopic Surgery: Potential Benefits

• Less tissue trauma• Reduced surgical stress response• Pulmonary function less impaired postoperatively • Less postoperative ileus• Reduced postoperative pain • Faster postoperative recovery and ambulation• Shorter hospital stay• Better cosmetic results• High patient satisfaction • Cost savings

�Mainly postoperative advantages�This has not been demonstrated for every procedure

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Laparoscopic Surgery: Technical Aspects

• Creation of working space– Pneumoperitoneum– Gasless lifting system– Combination

• Gravity as a retractor– Upper abdominal: reverse Trendelenburg positioning– Lower abdominal: Trendelenburg positioning (extreme)

• Robot-assisted

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Pneumoperitoneum : Ideal Insufflation Gas

• Nonflammable• Metabolically and chemically inert• Highly soluble in blood• Nontoxic• Odorless• Colorless• Readily available • Inexpensive

� Insufflation gas of choice: carbon dioxide (CO 2)

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Insufflation Gas: Solubility

Gas Solubility relative to nitrogen

Helium 0.7

Nitrogen 1.0

Oxygen 1.9

Argon 2.2

Nitrous oxide 33 .0

Carbon Dioxide 47.0

Wolf, Seminars in Surgical Oncology 12 (1996)

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Pneumoperitoneum : Insufflation Gas

• Carbon dioxide� Highly soluble in blood� Non-flammable� Hypercapnia� Irritation of diaphragma and peritoneum (� shoulder pain)� Used for the majority of laparoscopic cases

• Nitrous oxide� Highly soluble in blood (less soluble than CO2)� No irritation of diaphragm or peritoneum

• Surgery under local anesthesia

� Supports combustion• No major surgery possible

� Used occasionally

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CO2 – PP: Pathophysiologic Changes

• Absorption of insufflated CO 2

– Extraperitoneal > intraperitoneal insufflation• Increased intra-abdominal pressure (IAP)

– Intraperitoneal > extraperitoneal insufflation

� Cardiovascular effects� Pulmonary effects

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CO2 - PP: Absorption of Insufflated CO 2 (1)

Parameters affecting absorption of CO 2

• Approach: extraperitoneal vs intraperitoneal insuffla tion• Site of surgery: pelvic vs upper abdominal surgery• Intra-abdominal pressure• Duration of pneumoperitoneum• Subcutaneous emphysema

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Liem et al., Anesth Analg 81 (1995)

��

��

� � � �

0 5 10 15 20 25 30 35 4030

35

40

45

50

55

60

65

70

� Intraperitoneally

� Extraperitoneally

Time after insufflation (min)

PaCO2(mmHg)

}*

* P = 0.02

��

��

��

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CO2 - PP: Absorption of Insufflated CO 2 (2)

Extraperitoneal vs intraperitoneal insufflation• Intraperitoneal pneumoperitoneum

– Gas filled space lined by a membrane– Limited expansion (→ absorption is self-limiting)

• PaCO2 increase reaches plateau after 15 – 30 min

– Subcutaneous emphysema < 2 %

• Extraperitoneal pneumoperitoneum– Gas migrates into tissues (not confined by a membrane)– Gas progressively dissects tissues (absorption = unlimited)

• PaCO2 increase continues for much longer than 30 min

– High incidence of subcutaneous emphysema

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CO2-PP: Absorption of Insufflated CO 2 (3)

Upper vs lower abdominal surgery• Upper abdominal surgery: intraperitoneal insufflatio n

– PaCO2 increase during 15 – 30 min– PaCO2 increase of 20 – 30 % from baseline

• Lower abdominal surgery– Intraperitoneal insufflation

• PaCO2 increase during 15 – 30 min• PaCO2 increase of 10 – 15 % from baseline

– Extraperitoneal insufflation• PaCO2 increase continues (> 30 min)• PaCO2 increase is generally >> 30 % from baseline

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CO2 - PP: Absorption of Insufflated CO 2 (4)

• Approach: extraperitoneal vs intraperitoneal insuffla tion• Site of surgery: pelvic vs upper abdominal surgery• Intra-abdominal pressure

– Role at low IAP during intraperitoneal insufflation– More important during extraperitoneal insufflation?

• Duration of pneumoperitoneum– Important during extraperitoneal insufflation

• Subcutaneous emphysema– Complication– May result in severe hypercarbia– Incidence: extraperitoneal >>> intraperitoneal insufflation

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CO2 – PP: Pathophysiologic Effects

• Cardiovascular effects– Cardiac arrhythmias– Systemic hemodynamic effects– Regional hemodynamic effects

• Renal effects• Splanchnic perfusion• Venous stasis

• Pulmonary effects

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CO2 – PP: Cardiac Arrhythmias (1)

• Reflex increase of vagal tonus– Bradycardia, asystole, arrhythmias– Eliciting factors

• Stretching of the peritoneum– Insufflation!

• Electrocoagulation of the fallopian tubes

– Accentuated in case of• Superficial level of anesthesia• Patients on β – blocking drugs

– Treatment• Immediately interrupt insufflation• Atropine• Deepening of anesthesia after recovery of heart rate

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CO2 – PP: Cardiac Arrhythmias (2)

• Pathophysiologic hemodynamic changes– Arrhythmias due to acute changes caused by insufflation

• Early during insufflation

– Patients with cardiac disease may be at higher risk

• Gas embolism may cause cardiac arrhythmias• Increased PaCO 2?

– Arrhythmias also occur without a high PaCO2

– Arrhythmias do not correlate with magnitude of PaCO2

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CO2 – PP: Systemic Hemodynamic Effects

Mean arterial blood pressure ⇑⇑⇑⇑

Heart rate ⇔⇔⇔⇔ ⇑⇑⇑⇑

Central venous pressure ⇑⇑⇑⇑ ⇓⇓⇓⇓

Pulm. cap. wedge pressure ⇑⇑⇑⇑ ⇓⇓⇓⇓

Cardiac output ⇓⇓⇓⇓ ⇔⇔⇔⇔ ⇑⇑⇑⇑

Systemic vascular resistance ⇑⇑⇑⇑

Initiation of pneumoperitoneum (IAP > 10 mmHg)

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CO2 – PP: Systemic Hemodynamic Effects (1)

Pathophysiologic mechanism : Multifactorial• Autotransfusion effect

– Compression of splanchnic blood vessels

• Reduced venous return– Compression of vena cava inferior– Pooling of blood in the legs– Increased intrathoracic pressure

• Increased systemic vascular resistance– Mechanical mechanism– Release of neurohumoral factors

• Vasopressin

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CO2 – PP: Systemic Hemodynamic Effects (2)

Parameters influencing balance between mechanisms• Intra-abdominal pressure• Intravascular volume status• Patient positioning• PaCO2

• Associated cardiac disease• Anesthesia

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Compression of splanchnic vessels

Pneumoperitoneum : IAP ≤ 10 mmHg

⇑⇑⇑⇑ Cardiac output

Neurohumoraleffects

⇑⇑⇑⇑ Venous return (autotransfusion)

⇑⇑⇑⇑ Preload

CO ⇑⇑⇑⇑

⇑⇑⇑⇑ SVR

⇑⇑⇑⇑ Afterload

CO ⇓⇓⇓⇓

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Compression of v. cava Pooling of blood in legs

Pneumoperitoneum : IAP > 15 mmHg

⇑⇑⇑⇑ SVR

⇑⇑⇑⇑ Afterload

⇓⇓⇓⇓ Venous return

⇓⇓⇓⇓ Preload

Neurohumoraleffects

⇑⇑⇑⇑ ITP

⇓⇓⇓⇓ Cardiac output

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CO2 – PP: Systemic Hemodynamic Effects (3)

• Intravascular volume status– Hypovolemia increases the negative hemodynamic effects of an

increased IAP• No splanchnic recruitment• Aggravates SVR increase

• Patient positioning: influences SVR– Trendelenburg positioning

• Attenuates SVR increase

– Reverse Trendelenburg positioning• Pooling of blood in the lower limbs• Aggravates increase of SVR• Avoid before insufflation

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Figure 68-5 Changes in the cardiac index and systemic vascular resistance during laparoscopy in two groups of patients. For group 1 (controls, n = 10, yellow bars), pneumoperitoneum was induced with patients in a 10-degree head-up position. Group 2 (volume loaded, n = 10, blue bars) patients received 500 mL of lactated Ringer's solution before anesthesia induction and were insufflated in the supine position. Data are presented as the mean ± SEM.

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CO2 – PP: Systemic Hemodynamic Effects (4)

• PaCO2

– Moderate hypercarbia• Slight myocardial stimulation• Decreased systemic vascular resistance

– Severe hypercarbia• Decreased myocardial contractility• Decreased arrhythmia threshold

• Associated cardiac disease– More severe hemodynamic changes?

• Anesthesia– Vasodilatation reduces SVR increase– Negative inotropic effects of anesthetics

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CO2 – PP: Renal Effects

• Decreased diuresis, glomerular filtration rate, renal b lood flow– < 50 % of baseline values– Normalization after deflation

• Mechanism : compression– Direct renal parenchymal compression– Venous congestion (reduced flow in v. cava inferior)

• Clinical consequences?– Recuperation after release of pneumoperitoneum– Postoperative renal dysfunction in specific patients?

• Pre-existing renal dysfunction?

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CO2 – PP: Effects on Splanchnic Perfusion (1)

Mechanisms with opposing effects ���� less predictable effects• Mechanical compression: splanchnic blood flow decrease

– Abdominal organ microcirculation– Abdominal blood vessels

• Direct effect of CO 2 from the PP: splanchnic hyperemia

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CO2 – PP: Effects on Splanchnic Perfusion (2)

• Hepatoportal circulation– Decreased blood flow– Postoperative liver dysfunction?

• Pre-existing liver disease?

• Gastrointestinal blood flow– Effects on blood flow depend on IAP

• IAP < 12 mmHg: no blood flow decrease, but even moderate splanchnichyperemia

• IAP > 15 mmHg: pressure-induced blood flow decrease

– Splanchnic ischemia and bacterial translocation?

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CO2 – PP: Venous Stasis (1)

• Venous stasis in the lower limbs– Increased femoral venous pressure– Decreased femoral peak velocity

• Mechanisms– Increased IAP and compression of v. cava inferior– Reverse Trendelenburg positioning

• Pooling of blood in lower limbs

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CO2 – PP: Venous Stasis (2)

Increased risk of venous thrombosis?• Factors increasing risk vs open procedures

– Venous pooling in the legs– Longer lasting procedures

• Factors reducing risk vs open procedures– Earlier ambulation– Less surgery-induced hypercoagulability

• Minimal tissue trauma

� With thrombosis prevention: no increased risk– Low molecular weight heparins– Compressive stockings

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CO2-PP: Intra-Operative Pulmonary Effects (1)

CO2 – PP: may have significant pulmonary effects• Mechanisms

– Increased intra-abdominal pressure– CO2 - absorption

� Consequences for mechanical ventilation

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CO2-PP: Intra-Operative Pulmonary Effects (2)

Increased intra-abdominal pressure• Cranial displacement of diaphragm• Increased airway pressure• V/Q mismatches� Functional residual capacity: decrease� Thoracopulmonary compliance: decrease

– 30 – 50 % decrease in healthy persons

� Development of atalectasis� Risk of hypoxemia

� Generally no problem in healthy persons� Obese patients, patients with pre-existing pulmonary disease

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CO2-PP: Intra-Operative Pulmonary Effects (3)

PaCO2 increase• CO2 – absorption from the pneumoperitoneum

– 10 – 30 % PaCO2 increase (with constant minute volume)– Plateau after 15 – 30 min

• If no plateau: search for cause (subcutaneous emphysema?)

• Mechanical factors may also be responsible for an increase of PaCO2 during a pneumoperitoneum– V/Q mismatching

• Abdominal distension• Patient positioning (Trendelenburg)

– These mechanical factors contribute more to the PaCO2 increase in patients with cardiorespiratory disease than in healthy patients

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CO2-PP: Intra-Operative Pulmonary Effects (4)

• Monitoring of PaCO 2 changes during CO 2 - PP– Capnography is reliable in healthy patients– ASA II and III patients: PaCO2 and arterial-end tidal PCO2 gradient

increase more• COPD patients, children with cyanotic congenital heart disease• Hypercapnia may develop in the absence of an abnormal PETCO2

Wittgen et al. Arch Surg 1991

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CO2-PP: Postoperative Respiratory Effects (1)

• Increased minute ventilation� Elimination of absorbed CO2

– Increased respiratory rate– Increased PETCO2

– Up to 2 hours postoperatively– Increased work of breathing may be a problem in patients with serious

cardiopulmonary disease

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CO2-PP: Postoperative Respiratory Effects (2)

• Postoperative pulmonary function is better perserved aft erlaparoscopy than after laparotomy– Postoperative pulmonary dysfunction is less severe

• 75 % of preoperative values (50 % after laparotomy)

– Pulmonary function recovers faster• Generally within 24 - 48 h (3 - 5 d after laparotomy)

– Pulmonary dysfunction is less severe after gynecologic than afterupper abdominal laparoscopy

– Pulmonary dysfunction after laparoscopy is more severe and recoversslower in older patients, obese patients, smokers and patients withCOPD

• But also in these patients pulmonary function is better preserved afterlaparoscopy than after laparotomy

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CO2-PP: Postoperative Respiratory Effects (3)

• Diaphragm dysfunction is significant following upper abdominal laparoscopic surgery– Inhibition of phrenic discharge by visceral afferents from the

gallbladder area or somatic afferents from the abdominal wall

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Laparoscopy with CO2-PP: Complications (1)

• Veress needle / trocar trauma• Subcutaneous emphysema• Pneumothorax

PneumomediastinumPneumopericardium

• Gas embolism• Endobronchial intubation• Peripheral nerve damage

� Incidence: no precise data� Consequences may be severe

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Laparoscopy with CO2-PP: Complications (2)

• Anesthesiologist may be the first to notice signs of a complication, even if the event is surgery related

• Diagnosis may be difficult and delayed– E.g. Significant retroperitoneal hematoma may develop insidiously– Differential diagnosis of complications with pulmonary effects

• Endobronchial intubation• Subcutaneous emphysema• Capnothorax• Pneumothorax• Massive CO2 embolism

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Veress Needle / Trocar Trauma

• Injury to large blood vessels– Aorta, inferior v. cava, iliac vessels

• Injury to abdominal wall vasculature• Retroperitoneal hematoma

– Concealed bleeding � difficult diagnosis• Abdominal organ perforation

– Small / large bowel, liver, spleen– Avoid gastric distension

• Diafragm , pleura, pericard perforation

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CO2 – PP: Subcutaneous Emphysema (1)

• Severe hypercapnia– Persisting in spite of increasing minute ventilation

• Mechanism– Accidental extraperitoneal CO2 insufflation– Side-effect of intentional extraperitoneal CO2 - PP

• Diagnosis– Sudden large increase in PETCO2 after PETCO2 had reached a plateau

• PETCO2 increase larger than 30 % from baseline• PETCO2 increase later than 30 min after beginning of insufflation

– Crepitus: abdominal wall, chest wall• Sometimes there is ocular and/or pharyngeal emphysema

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CO2 – PP: Subcutaneous Emphysema (2)

• Intraoperative management– Increase minute ventilation

• Sometimes it is impossible to sufficiently increase MV

– Reduce insufflation pressure– Muscle relaxation

• May facilitate mechanical ventilation (?)

– If PETCO2 remains too high• Limit duration of surgery• Desufflate intermittently• Abolish laparoscopic procedure

– Determined by PETCO2 and cardiopulmonary status

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CO2 – PP: Subcutaneous Emphysema (3)

• Postoperative attention points– Subcutaneous CO2 readily resolves after desufflation– Keep patient mechanically ventilated until hypercapnia is sufficiently

corrected• This avoids excessive work of breathing

– Be aware of risk of pharyngeal emphysema• Generally, patients can be extubated, but if in doubt check presence of

air leak with deflated cuff

Anesthesia and Analgesia 1995; 80: 201 - 203

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CO2-PP: Pneumothorax, Pneumomediastinum , Pneumopericardium

• Increased PETCO2

• Pneumothorax: differentialdiagnosis– Capnothorax– CO2 pneumothorax

• Combination

From: Wolf and Stoller, J. Urol. 152 (1994)

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CO2 – PP: Pneumothorax vs Capnothorax

Pneumothorax (lung injury)

• PETCO2 decrease• IPPV � risk of tension pneumo-

thorax• Chest drain is generally

indicated

Capnothorax(CO2 pneumothorax)

• PETCO2 increase• IPPV (+ PEEP) � reduction of

capnothorax• Chest drain is not always

necessary

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CO2 - PP: Gas Embolism (1)

• Venous CO 2 embolism– Early after Veress needle insertion (during induction of PP)

• Direct intravenous insufflation• Insufflation in abdominal organs�Gas lock in v. cava and right atrium � fall in cardiac output, even

circulatory arrest– Passage of CO2 into abdominal wall and peritoneal vessels– Open vessels on liver surface during gallbladder dissection

• Paradoxal embolism through patent foramen ovale or ASD– Acute right ventricular hypertension– Cerebral CO2 embolism

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CO2 - PP: Gas Embolism (2)

• Lethal volume of CO 2 embolism is five times greater than of air• Signs and symptoms

– Decrease in PETCO2

• Sometimes preceded by a brief increase in PETCO2 due to pulmonaryexcretion of absorbed CO2

– “Mill-wheel” murmur– Hypoxemia– Hypotension– Cardiovascular collapse

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CO2 - PP: Gas Embolism

No physiologic changes •Precordial doppler•Transesophageal echocardiography

Modest physiologic changes •Decreased PETCO2•Increased pulmonary artery pressure

Clinical symptoms •Decreased blood pressure•Increased central venous pressure•Decreased cardiac output

Cardiovascular collapse •ECG changes•Arrhythmias•Aspiration of foamy blood from centralvenous line•Esophageal stethoscope

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CO2 - PP: Gas Embolism (3)

• Immediately stop insufflation and release pneumoperi toneum• Ventilation with 100 % oxygen

– Hyperventilation

• Durant’s position to clear right ventricular outflo w– Left lateral decubitus– Steep Trendelenburg

• Aspiration of gas (central venous catheter)• Cardiopulmonary resuscitation

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CO2 – PP: Endobronchial Intubation

• Cephalad displacement of the diaphragm (and carina)• Increase in airway pressure• O2 saturation decrease

Lobato et al., Anesth Analg 1998; 86: 301 - 303

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Peripheral Nerve Damage

Careful positioning• Head-down position

– Shoulder braces: risk of brachial plexus lesion– Vacuum matress is a better choice

• Lithotomy position– Common peroneal nerve lesion– Long-lasting procedures: compartment syndrome

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CO2 – PP: Contra-indications (1)

• Patients with or at risk for an increased ICP – Cerebral trauma– Intracranial space occupying lesions (tumor, aneurysm)– Hydrocephalus

ICPBaseline PP

(15 mmHg)Epid

balloonEB + PP EB +

Retractor

Pressure(mmHg)

� � � � �

� � � � �

0

10

20

30

0

20

40

60

80

100Pressure(mmHg)

� MAP� PaCO2

Este-McDonald et al., Arch Surg 130 (1995)

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CO2 – PP: Contra-indications (2)

• Significant hypovolemia– Pronounced hemodynamic effects of increased IAP

• Low cardiac output• Renal and splanchnic hypoperfusion

• Selected cardiopulmonary problems– Very low cardiac output– Severe heart failure– Cardiac right-left shunt– Severe aortic valve insufficiency– Severe pulmonary hypertension– Some complex congenital cardiopathies

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CO2 – PP: Relative Contra-indications (1)

• Heart failure • Patent foramen ovale• Severe pulmonary disease

– Intra-operative ventilation problems– Less postoperative pulmonary dysfunction

• Significantly impaired renal function?– Avoid prolonged laparoscopic surgery with high IAP?– Hemodynamic optimalization– Avoid nephrotoxic drugs

• Patients at risk for splanchnic ischemia?– Avoid prolonged laparoscopic surgery with high IAP?

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CO2 – PP: Relative Contra-indications (2)

• Increased intraocular pressure?– There is no increase in intraocular pressure in patients without pre-

existing eye disease– Uncontrolled glaucoma?

• Trendelenburg positioning can increase intraocular venous pressure and worsen acute glaucoma

• Clinical significance?

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Anesthesia for Laparoscopy with CO2 – PP (1)

• Preoperative evaluation– Contra-indications– Thrombosis prophylaxis

• Premedication– Outpatient vs hospitalization– Antacids? No.

• No indication of increased risk of regurgitation

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Anesthesia for Laparoscopy with CO2 – PP (2)

• Monitoring– Standard intraoperative monitoring

• Blood pressure, heart rate, ECG, capnometry, pulse oxymetry� Only indirect evidence of PP-induced hemodynamic changes

– Arterial line• Severe pre-existing cardiac and pulmonary disease

– Hemodynamic response to PP + positioning– Arterial – end tidal PCO2 difference

• Surgical procedure

– Transesophageal echocardiography• Severe cardiac co-morbidity, but indication for laparoscopy?

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Anesthesia for Laparoscopy with CO2 – PP (3)

• Epidural anesthesia– Extensive block is necessary (T4 - L5) for surgical laparoscopy– Short procedures– Reduced insufflation pressure– No extreme head-down positioning– Hemodynamic effects of PP under epidural anesthesia: no data– Insufflation gas

• Nitrous oxide?– Less irritation of peritoneum and diaphragm– No electrocautery possible

• CO2

– Increased minute ventilation (increased work of breathing) to maintain PaCO2

� For selected procedures only

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Anesthesia for Laparoscopy with CO2 – PP (4)

• General anesthesia: technique of choice for laparos copy– Intubation and mechanical ventilation

• Technique of choice• Adjust minute volume to maintain PETCO2 between 35 - 40 mmHg• Check position of endotracheal tube after induction of PP

– Risk of endobronchial intubation– Check again with Trendelenburg positioning

• Laryngeal mask?– Does not protect airway against aspiration of gastric contents– Ventilation problems

» ↓ thoracopulmonary compliance and airway pressure > 20 cmH2O» ProSeal laryngeal mask?

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Anesthesia for Laparoscopy with CO2 – PP (5)

• General anesthesia: technique of choice for laparos copy– Antiemetic

• Laparoscopy: increased risk of PONV (40 – 75% of patients)

– Nitrous oxide ? Controversial• Bowel distension?

– Not convincingly demonstrated• Worsens cardiovascular effects of CO2 emboli• Explosion hazard?

– Bowel perforation and combustion of bowel gases– Unlikely in routine clinical practice

• Increased incidence of PONV?�No conclusive evidence against the use of N2O

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Anesthesia for Laparoscopy with CO2 – PP (6)

• Recovery and postoperative care– Postoperative CO 2 elimination

• Absorption of residual CO2

• CO2 release from body stores�Increased work of breathing

�Caution in patients with severe cardiopulmonary disease– Nausea and vomiting

• Prevention indicated

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Anesthesia for Laparoscopy with CO2 – PP (7)

• Postoperative analgesia– Incisional pain, intra-abdominal (visceral) pain, sh oulder pain– After laparoscopy pain is generally less intense an d of shorter

duration than after laparotomy, but• Pain is variable in duration, severity and character• Patients may experience severe pain after laparoscopic surgery

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Anesthesia for Laparoscopy with CO2 – PP (8)

• Postoperative analgesia: multimodal approach– Intraperitoneal local anesthetic

• Conflicting results• More successful after pelvic laparoscopy • Generally not effective for visceral pain

– Infiltration of skin with local anesthetic – Evacuation of insufflation gas

• Residual CO2 causes shoulder pain• Gas drain

– NSAIDs• Reduced need for opioid analgesia

– Opioids may be necessary!