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Anesthesia for Laparoscopic Surgery 2007.4.13 R1 陳鈞婷 / 黃俊仁主任 Miller ’ s Anesthesia, 6th edition, Chapter 57 Benefits- reduce trauma,morbidity, mortality, hospital stay, health care costs, better maintenance of homeostasis

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anesthesia for laparoscopic surgery

Anesthesia for Laparoscopic Surgery

2007.4.13

R1陳鈞婷/黃俊仁主任

Miller’s Anesthesia, 6th edition, Chapter 57

slide2
Benefits- reduce trauma,morbidity, mortality, hospital stay, health care costs, better maintenance of homeostasis
  • Complications- pathophysiologic changes, longer duration, unsuspected visceral injury, evaluating blood loss
respiratory complications
Respiratory complications
  • CO2 pneumoperitoneum
    • CO2 subcutaneous emphysema
    • Pneumothorax
    • Endobronchial intubation
    • Gas embolism
ventilatory changes
Ventilatory Changes
  • ↓thoracopulmonary compliance (30-50%) in healthy, obese, ASA III/IV
  • ↓FRC due to diaphragm elevation
  • No change in physiologic dead space or shunt in healthy pat. when intra abdominal pressure(IAP) to 14mmHg and 10-200 tilt
slide5
PaCO2 plateau 15-30mins
  • PaCO2 depends on IAP
  • Local anesthesia – PaCO2 unchanged, ↑minute ventilation
  • IV general – compensatory hyperventilation insufficient due to respiratory depresssion and decreased compliance ∴ ↑PaCO2
    • Post op :↑resp rate, PETCO2
slide6
Mean gradient(Δa-ETCO2) between PaCO2 and PETCO2 ↑more in ASA II/III than in ASA I
    • Eg.COPD, congenital heart disease
  • Lack of correlation between PaCO2 and PETCO2 in sick patients
    • Impaired CO2 excretion capacity
  • ABG recommended when hypercarbia suspected
slide7
Ventilatory changes
  • ASA I & II
  • Minute ventilation 100ml/kg/min
  • RR 12/min
slide8
Ventilatory changes
  • Open circles ASA I
  • Red circles ASA II-III
causes of increased paco 2 during laparoscopy
Causes of increased PaCO2 during laparoscopy
  • Absorption of CO2 from peritoneal cavity(main cause)
  • V/Q mismatch
      • Increased physiologic dead space, ↓alveolar ventilation
      • Abdominal distention
      • Position (eg. Steep tilt)
      • Controlled mechanical ventilation
      • Reduced cardiac output
      • Accentuated in sick patients
  • Increased metabolism(eg.insufficient anesthesia)
  • Depression of ventilation(eg.spontaneous breathing)
  • Accidental events :CO2 emphysema, Capnothorax, CO2 embolism, selective bronchial intubation
co 2 subcutaneous emphysema
CO2 Subcutaneous Emphysema
  • Extraperitoneal insufflation
    • Eg. Inguinal hernia, renal surgery, pelvic lymphadenectomy
  • PaCO2 and PETCO2 increase after plateaued
  • Resolves after desufflation
  • Does not counterindicate tracheal extubation
pneumothorax pneumomediastinum pneumopericardium
Pneumothorax Pneumomediastinum Pneumopericardium
  • Embryonic remnants potential channels, Rt peritoneopleural ducts
  • Diaphragmatic defects, aortic and esophageal hiatus, pleural tears
  • Lung bullae
  • Capnothorax - ↓compliance, ↑airway pressure
  • Caution tension pneumothorax
capnothorax management no lung trauma
Capnothorax Management(no lung trauma)
  • Stop N2O administraion
  • Adjust ventilator settings to correct hypoxemia
  • Apply PEEP
  • Reduce IAP as much as possible
  • Maintain close communication with surgeon
  • Avoid thoracocentesis unless necessary, spontaneous resolution after exsufflation
slide13
Pneumothorax from ruptured bullae
    • No PEEP
    • Thoracocentesis is required
endobronchial intubation
Endobronchial Intubation
  • Cephalad displacement of diaphragm
  • Can occur in head up or down position
  • ↓SpO2
  • ↑plateau airway pressure
gas embolism
Gas Embolism
  • CO2 more soluble than air, O2, N2O
  • Bicarbonate buffering, binding with Hb, plasma proteins, rapid elimination
  • Lethal dose >5x of air
  • Size and rate
  • Patent foramen ovale – emboli to coronary, brain
  • V/Q mismatch : physiologic dead space, hypoxia
gas embolism16
Gas Embolism
  • <0.5ml/kg of air
    • ↑mean PAP
  • 2ml/kg of air
    • Tachycardia, arrhythmias, hypotension, ↑CVP, cyanosis, Rt heart strain
  • ↓PETCO2
    • ↓cardiac output
    • ↑physiologic dead space
    • Initial increase in CO2 excretion
treatment of co 2 embolism
Treatment of CO2 embolism
  • Stop pneumoperitoneum
  • Steep head down and left lateral decubitus position
  • 100% O2
  • Hyperventilation
  • Central venous line – aspirate gas
    • Foamy blood
  • External cardiac massage – break gas into small bubbles
hemodynamic effects
Hemodynamic effects
  • Lower limb venous stasis
    • Literature : laparoscopy no ↑in DVT
  • ↓urine output and GFR
  • ↑cerebral blood flow
  • Arrhythmias
    • ↑Vagal tone (sudden peritoneum stretch, electrocoagulation of fallopian tubes) → bradycardia, arrhythmias, asystole
    • Vagal stimulation when low level anesthesia, B-blockers
    • Gas embolus
positioning effects
Positioning effects
  • Head down : ↑CVP and cardiac output
    • Affect patients with coronary artery disease
    • Elevation intraocular venous pressure(worsen acute glaucoma)
    • Increase risk of gas embolism
    • Atelectasis
    • Decreased FRC, total lung volume, compliance
  • Head up
    • ↓venous return →↓cardiac output and BP
laparoscopy during pregnancy
Laparoscopy during Pregnancy
  • Risk of miscarriage, premature labour, fetal acidosis
  • Maternal PaCO2 maintained at normal level, fetal placental perfusion pressure, blood flow, pH then unaffected
  • Recommendations:
    • 2nd trimester, minimize preterm labor, adequate working room
    • Debatable use of tocolytics to arrest preterm labor
    • Open laparoscopy to avoid damaging uterus
    • Fetal monitoring with transvaginal ultrasonography
    • Mechanical ventilation to maintain physiologic maternal alkalosis
anesthesia for laparoscopy
Anesthesia for laparoscopy
  • Positioned to prevent nerve injury
  • Tilt should not exceed 15-20 degrees
  • ET tube checked after position change
  • Monitors – BP,HR,EKG,CO2,SpO2
  • ABG to correctly analyze PaCO2
  • GA : safest technique compared to local, regional
  • Increase RR rather than tidal volume in COPD, spontaneous pneumothorax, bullous emphysema
slide25
Post op: hemodynamic changes(eg.↑SVR) outlasts the release of pneumoperitoneum
  • Increased O2 demand after laparoscopy
  • Higher RR and PETCO2 higher after laparoscopy
  • Prevention of nausea, vomiting