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The place of Sugammadex (Bridion ® ) in laparoscopic bariatric surgery. 1150 1850 1947 1977 2010 . Jan Paul Mulier, MD PhD Sint Jan Brugge-Oostende. Overview. Current state of reversal

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the place of sugammadex bridion in laparoscopic bariatric surgery

The place of Sugammadex (Bridion®) in laparoscopic bariatric surgery

1150 1850 1947 1977 2010

Jan Paul Mulier, MD PhD

Sint Jan Brugge-Oostende

4 03 2010 J P Mulier

overview
Overview
  • Current state of reversal
    • Limitations / Potential risks with residual blockade
    • Techniques to reduce need for reversal
  • Reversal with bridion® (Sugammadex)
    • Mechanism of action / Pharmacokinetics, pharmacodynamics
    • Efficacy / Safety - Practical dosage
  • Indications for bridion ® (Sugammadex)
    • “Can not intubate / can not ventilate”
    • Rapid sequence induction for short procedures
    • Continuous deep blockade till end of surgery
    • Sudden / not predicted / need for awakening
    • Need for an amfetamine like arousal effect
  • Practical use in bariatric laparoscopy
    • Anaesthesia induction
    • Anaesthesia maintenance
    • Anaesthesia awakening ERAS technique of Bruges

4 03 2010 J P Mulier

limitations of cholinesterase inhibitors
Limitations of Cholinesterase Inhibitors

Relatively slow in reversing neuromuscular blockade

Insufficient or impossible to reverse deep blockade

Require concomitant administration of anticholinergics

Well-known side effect profile

Bartkowski RR. Anesth Analg. 1987;66:594-598.

Kim KS et al. Anesth Analg. 2004;99:1080-1085.

Kopman AF et al. J Clin Anesth. 2005;17:30-35.

4 03 2010 J P Mulier

neostigmine 50 g kg inadequately reverses 95 twitch depression
Neostigmine (50 µg/kg) Inadequately Reverses 95% Twitch Depression

Vecuronium Protocol

T1 = 100%

Hatched area = height of T1

T1 = 50%

Solid area = height of T4

NEO administered

10 min

20 min

30 min

Rocuronium Protocol

NEO, neostigmine; ROC, rocuronium; TOF, train-of-four.

Kopman AF et al. J Clin Anesth. 2005;17:30-35.

4 03 2010 J P Mulier

side effects associated with current reversal agents
Side Effects Associated With Current Reversal Agents

ChE inhibitors in the reversal can cause

Bradycardia / Hypersalivation

Bronchospasm / Increased bronchial secretions

Urinary frequency / Nausea and vomiting

Coadministration of antimuscarinic agents

Tachycardia

Dryness of mouth and nose

Mydriasis / Urinary retention

Neostigmine Methylsulfate Injection [package insert]; 2002.

Atropine Sulfate Injection, USP [package insert]; 2003.

Glycopyrrolate Injection, USP [package insert]; 2006.

ChE, cholinesterase.

*Atropine use causes dose-dependent adverse effects.

4 03 2010 J P Mulier

increased risk associated with residual blockade
Increased Risk AssociatedWith Residual Blockade

Increased risk of postoperative pulmonary complications

coughing, expectoration, pain when breathing, increased risk of aspiration; Hypoxemia, hypercapnia, the need for reintubation, non invasive ventilation

delay in meeting PACU discharge criteria and achieving actual discharge

Berg H et al. Acta Anaesthesiol Scand. 1997;41:1095-1103.

Bissinger U et al. Physiol Res. 2000;49:455-462.

Eikermann M et al. Anesth Analg. 2006;102:937-942.

Murphy GS. Minerva Anestesiol. 2006;72:97-109.

PACU, post anaesthesiology care unit

4 03 2010 J P Mulier

what was our answer before bridion
What was our answer before Bridion?
  • Waiting for reversal before awakening, extubation and transfer to PACU
    • Turnover time increased or ventilation in PACU
  • Incomplete reversal at extubation
    • If patient can breath it is oke?
    • If patient can lift head it is oke?
    • Ad midazolam so patients are not aware?
  • Earlier decurarisation (spont or neostigmine)
    • Is every surgeon happy?
  • Extra dose neostigmine
    • has only little effect but could even worsen decurarisation.
  • Inject water instead of NMB
    • To make your surgeon happy?
      • Be a transdisciplinary team
      • do you really know what surgeons think?

4 03 2010 J P Mulier

my technique before bridion to reduce the need for reversal in laparoscopy
My technique (before Bridion) to reduce the need for reversal in laparoscopy

Measure Abdominal Compliance

  • Measure abdominal compliance and give less relaxants if Compliance is large.
  • Or use 2 MAC deep inhalation anaesthesia at end surgery.
    • Use pressure support ventilation to prevent patient from breathing against ventilator.

4 03 2010 J P Mulier

are nmb needed
Are NMB needed ?
  • Gynecologic laparoscopy without curare is possible.
    • Chassard D. Ann Fr Anesth Reanim. 1996;15(7):1013-7
  • Only when compliance is very high?
  • Or when surgeons do not complain?

4 03 2010 J P Mulier

apvr description
APVR description
  • Measure pressure volume relation
  • Angle is compliance or elastance E
  • Section with Y axis is PV0: pressure at zero vol

P = 3,30 V + 8,40 mmHg

Squared R = 0,96

E : 3,3 mmHg/L

PV0 : 8,4 mmHg

4 03 2010 J P Mulier

e en pv0 determined by
E en PV0 determined by ?
  • Mulier Dillemans ESA 2007

4 03 2010 J P Mulier

patient with no effect of nmb
No muscles in abd wall, diaphragm ?

Fully relaxed by other factors ?

Patient with no effect of NMB
  • TOF > 90%
  • TOF = ¼
  • TOF 0/4 and PTC < 5

4 03 2010 J P Mulier

why nmb sometimes have no effect on apvr
Why NMB sometimes have no effect on APVR?
  • Muscle total relaxed before giving NMB.
    • Deep anesthesia?
    • Volatile anesthetics?
  • Muscle very thin or non existent
  • Muscle fascia parallel

4 03 2010 J P Mulier

effect of valsalva breathing against ventilator
Valsalva is an active muscle contraction different from breathing to increase the abdominal pressure

Happens when patient reacts on Controlled Ventilation

Effect of valsalva: breathing against ventilator

4 03 2010 J P Mulier

bmi effect on abdominal p v relation
J Mulier ISPUB 2009

Pressure volume relation is linear

PV0 and E define each patient

J Mulier IFSO 2007

BMI effect on abdominal P/V relation

4 03 2010 J P Mulier

waist to hip ratio whr
Waist to Hip ratio (WHR)
  • Man normal WHR: 0,9
  • Woman normal WHR: 0,7
  • Android fat distribution
    • WHR > 0,8
  • Gynoid fat distribution
    • WHR < 0,8

4 03 2010 J P Mulier

remember patient type with a high mortality risk
Remember:Patient type with a high mortality risk
  • Elderly male diabetes patient with hypertension and being super obese, no weigth loss.
    • Buchwald 2007
  • Central abdominal fat, not stopped smoking, alcoholic
    • General risk
  • Asthma and coronary artery disease
    • Cardio pulmonary risks

4 03 2010 J P Mulier

two types of android obesity
Two types of android obesity

Subcutaneus FatVisceral fat

Intra visceral adiposity Extra visceral adiposity

Subcutaneus fat is scant and Subcutaneus fat is thick and

intra abdominal fat is thick and intra abdominal fat is scant.

4 03 2010 J P Mulier

the obese patient is a challenge for anaesthesia if android shape with intra visceral fat
The obese patient is a challenge for anaesthesia if android shape with intra visceral fat.

4 03 2010 J P Mulier

nmb effect on e pv0
NMB effect on E - PV0
  • E or Compliance unchanged
    • E determined by fascia, size and shape
  • PV0 drops =extra volume at same pressure

4 03 2010 J P Mulier

how to change pv0
How to change PV0?

Mulier Dillemans 2008

  • NMB
  • Inhalation anesthesia > 2 MAC
  • Table inclination: trendelenburg
  • Smaller tidal volume ventilation
  • Lower peep

4 03 2010 J P Mulier

how to change e hip flexion
How to change E : hip flexion
  • Mulier JP, Dillemans B Obes Surg 2009

4 03 2010 J P Mulier

begin end of first laparoscopy
Begin – End of first laparoscopy
  • Abdominal compliance changes during pneumoperitoneum
  • Inflation volume rises more than 1 liter!
  • No NMB needed at end of operation ?

One Hour Laparoscopy at 15 mmHg Elongates the Abdominal Wall

Mulier IFSO 2009

4 03 2010 J P Mulier

laparoscopy without muscle relaxants
Laparoscopy without muscle relaxants ?
  • Laparoscopy is possible without muscle relaxants or at reduced dose if
    • adominal compliance > 0,5 L/mmHg
    • IAV > 4 L at 15 mmHg at start laparoscopy
      • Gravidity > 3
      • Previous multiple laparoscopies/laparotomies
      • > 10 kg weight reduction
      • No man with android fat distribution

and

    • Sufficient deep sleep
      • As patient should not breath against ventilator.
    • Pressure support ventilation
      • Easier to prevent breathing against ventilator

4 03 2010 J P Mulier

are nmb needed in laparoscopy
Are NMB needed in laparoscopy?
  • No if abdominal compliance is large
  • Yes as inflation pressure can be lower
  • Yes to prevent breathing agains ventilator
  • After one hour laparoscopy compliance is rosen

4 03 2010 J P Mulier

slide28
PSV
  • PSV is not a valsalva effect: IAV is not changing.
  • PSV is possible during deep muscle relaxation.

PROFOUND MUSCLE RELAXATION DOES NOT DISTURB

PRESSURE SUPPORT VENTILATION.

Mulier J, Blacoe D PGA 2009

4 03 2010 J P Mulier

is deep relaxation needed and possible
Is deep relaxation needed and possible?
  • Time between end pneumoperitoneum and end operation is very short: in 5 min from TOF 0/4 -¼ till 90% is not possible with neostigmine.
  • Sugammadex
    • TOF 0/4 till end pneumoperitoneum
    • Very deep NMB PTC < 5 is possible till the end

4 03 2010 J P Mulier

effect deep muscle relaxation on iap with constant iav
Effect deep muscle relaxation on IAP with constant IAV
  • Gradual pressure drop until flat line
  • Max effect at TOF 0/4
  • At PTC 0 no extra pressure drop

TOF 4/4 TOF ¼ PTC 10 PTC 5 PTC 0

4 03 2010 J P Mulier

effect of deep muscle relaxation on abdominal pv loop
Effect of deep muscle relaxation on abdominal PV loop
  • TOF > 90%
  • TOF = ¼ - 0/4
  • TOF 0/4 and PTC < 5

4 03 2010 J P Mulier

conclusion nmb needed
Conclusion: NMB needed
  • Yes
    • Larger surgical workvolume for lower pressures
    • At low pressures less structural damage and less post op pain?
    • Sometimes no sufficient workspace and angry surgeons: try to do everything.
  • No
    • Abd Compliance sometimes large enough
    • Work at higher intra abd pressure?
    • 2 MAC inhalation has same effect?
    • Effect of position and of time?

Meten is weten (Measuring is knowing!)

4 03 2010 J P Mulier

if yes decurarisation needed
If Yes -> decurarisation needed
  • Only Brideon is able to do so ?

4 03 2010 J P Mulier

bridion s mechanism of action is unlike traditional reversal agents
Bridion’s Mechanism of Action Is Unlike Traditional Reversal Agents

NMB

Conventional NMB Reversal

AChE

AChE

Choline+acetate

Choline+acetate

NMBA

ACh

ACh

ChE inhibitors(eg, neostigmine)

nAChR

nAChR

Reversal With Bridion

AChE

Choline+acetate

NMBA

ACh

Hostmolecule

nAChR

NMBA

ACh, acetylcholine; AChE, acetylcholinesterase.ChE, cholinesterase; nAChR, nicotinic acetylcholine receptor;NMBA, neuromuscular blocking agent; NMB, neuromuscular blockade.

Adam JM et al. J Med Chem. 2002;45:1806-1816.

4 03 2010 J P Mulier

encapsulation of rocuronium by bridion
Encapsulation of Rocuronium By Bridion

Cameron KS et al. Org Lett. 2002;4:3403-3406.

Gijsenbergh F et al. Anesthesiology. 2005;103:695-703.

4 03 2010 J P Mulier

what happens when bridion is injected
What happens when Bridion is injected?

= Esmeron

4 03 2010 J P Mulier

what happens when bridion is injected38
What happens when Bridion is injected?

= Bridion - Esmeron complex

4 03 2010 J P Mulier

what happens when bridion is injected39
What happens when Bridion is injected?

= Bridion - Esmeron complex

4 03 2010 J P Mulier

what happens when bridion is injected40
What happens when Bridion is injected?

= Bridion - Esmeron complex

4 03 2010 J P Mulier

bridion pharmacokinetics
Bridion Pharmacokinetics

Vss 11 to 14 L

T½ elimination 1.8 hours

Cl estimated to be ~88 mL/min

Major route of elimination: renal

96% of the dose excreted in urine, of which at least 95% could be attributed to unchanged Bridion

Cl, clearance; T½, half-life; Vss, volume of distribution at steady state.

Data on file.Bridion® [summary of product characteristics]Organon, Europe; 2008.

4 03 2010 J P Mulier

various depths of blockade
Various Depths of Blockade

Intense block: no response to either TOF or PTC stimulation

Deep block: response to PTC but not to TOF stimulation

Moderate block: reappearance of response to TOF stimulation

Superficial block: reappearance of T4 T4/T1 ratio > 1%

No block: T4/T1 ratio > 90 %

Posttetaniccount

Twitchresponse

Twitchpercentage

Level of block

Intense block

Deep block

Moderate block

Superficial block

TOF count 4

Response to TOF

TOF count 0

TOF count 0

TOF count 1-3

T1/T4 %

Response to PTC

PTC ≥1

PTC 0

PTC, posttetanic count; TOF, train-of-four.

Fuchs-Buder T et al. Acta Anaesthesiol Scand. 2007;51:789-808.

4 03 2010 J P Mulier

increased flexibility in the time of reversal
Increased Flexibility in the Time of Reversal

Immediate Reversal*

Within 3 min following administration of rocuronium, 16 mg/kg

Routine Reversal

4 mg/kg if recovery has reached 1–2 PTC (deep blockade)

2 mg/kg if spontaneous recovery has reached the reappearance of T2 (moderate blockade)

Bridion allows full relaxation until the end of surgical procedures

*Only recommended with rocuronium-induced blockade.PTC, posttetanic count.

Data on file.Bridion® [summary of product characteristics]. Organon, Europe; 2008.

4 03 2010 J P Mulier

recommended dosage
Recommended dosage
  • 16 mg/kg intense block
  • 4 mg/kg deep block
  • 2 mg/kg all other blocks
  • Maximum safety:
    • overloading t1/2 longer than roc
    • Fastest reversal
    • Never recurarisation
    • Individual variation covered
  • Less?
    • No studies yet
    • Re-occurrence of relaxation
  • TBW or IBW ?
    • No studies yet but as rocuronium is dosed according to IBW and has the same water solubility ???
  • Combination with neostigmine is possible but you get the side effects back.

4 03 2010 J P Mulier

practical bridion use
Practical bridion use

Vial 2 ml, 100 mg/ml 200 mg per vial

  • 2 mg/kg in a 70 kg person:
    • 140 mg one vial
  • 2 mg/kg in a 200 kg person:
    • 400 mg or two vials or IBW 140 mg?

Is the patient, willing to pay for it?

  • Yes if
    • previous history of rest curarisation
    • you explain that procedure
      • is otherwise not safe
      • might take longer
      • Is not possible
    • You prevent post op complications?

4 03 2010 J P Mulier

measure depth of blockade
Measure Depth of Blockade

Intense block: 16 mg/kg

Deep block: 4 mg/kg

Moderate block: 2 mg/kg + Neostigmine?

Superficial block: 1 mg/kg + Neostigmine?

No block: 0 mg/kg

Posttetaniccount

Twitchresponse

Twitchpercentage

Level of block

Intense block

Deep block

Moderate block

Superficial block

TOF count 4

Response to TOF

TOF count 0

TOF count 0

TOF count 1-3

T1/T4 %

Response to PTC

PTC ≥1

PTC 0

PTC, posttetanic count; TOF, train-of-four.

Fuchs-Buder T et al. Acta Anaesthesiol Scand. 2007;51:789-808.

4 03 2010 J P Mulier

more rapid recovery with bridion from t 2 following rocuronium
More Rapid Recovery With Bridion From T2 Following Rocuronium

(%)

Bridion 2 mg/kg

Rocuronium 0.6 mg/kg

100

50

10:21:06

10:32:38

10:44:08

10:55:38

11:07:08

11:18:53

11:30:38

11:42:08

11:53:53

12:04:39

12:13:56

(%)

Rocuronium 0.6 mg/kg

Neostigmine 50 µg/kg

100

50

7:49:34

7:59:34

8:09:34

8:19:34

8:29:49

8:39:49

8:50:03

9:00:19

9:10:19

9:20:34

9:30:49

9:41:04

TOF ratioTwitch height

TOF, train-of-four.

Data from Aurora trial.

4 03 2010 J P Mulier

faster reversal from rocuronium at reappearance of 2 counts
Faster Reversal from Rocuronium at reappearance of 2 Counts

Bridion 4 mg/kg

NEO 70 µg/kg

n = 37

n = 37

95% CI (2.3–3.3 min)

95% CI (35.7–59.5 min)

CI, confidence interval, NEO, neostigmine.

Data from Signal trial.

4 03 2010 J P Mulier

time from t 1 10 to 90 within subject
Time From T1 10% to 90% Within Subject

20

n = 56

n = 54

15

Minutes

10

5

0

T1=10%

T1=90%

T1=10%

T1=90%

Rocuronium 1.2 mg/kg +Bridion 16 mg/kg

Succinylcholine 1.0 mg/kg

Data from Spectrum trial.

4 03 2010 J P Mulier

immediate reversal of intense blockade
Immediate Reversal of Intense Blockade

10.9

*

7.1

3.2

*

1.4

3 min

Bridion

administered

n = 56

n = 54

n = 56

n = 54

T1 to 90%

T1 to 10%

*P < 0.0001 versus succinylcholine treatment group; results based on intent-to-treat population.SEM, standard error of mean.

Data from Spectrum trial.

4 03 2010 J P Mulier

rapid dose dependent reversal from t 2 in children and adolescents following rocuronium 0 6 mg kg
Rapid Dose-Dependent Reversal FromT2 in Children and AdolescentsFollowing Rocuronium 0.6 mg/kg

TOF, train-of-four.*Approved dose in children and adolescents.

Data from Libra trial.

4 03 2010 J P Mulier

no dose adjustment required with increasing age
No Dose Adjustment Required With Increasing Age

n = 48

n = 40

n = 62

Age, yr

Data from Diamond trial.Bridion® [summary of product characteristics]. Organon, Europe; 2008.

TOF, train-of-four. *Reversal from T2 following rocuronium 0.6 mg/kg

4 03 2010 J P Mulier

bridion has a demonstrated safety profile
Bridion Has a Demonstrated Safety Profile

Bridion has been studied in >2000 clinical trial subjects

Safety has been demonstrated in patients with cardiac and pulmonary disease

Bridion is not recommended in patients with severe renal failure (CrCl <30 ml/min)

Great caution should be taken in patients with severe hepatic disease

Dedicated studies in this population have not taken place

Data on file.Bridion® [summary of product characteristics]. Organon, Europe; 2008.

CrCl, creatinine clearance.

4 03 2010 J P Mulier

drug drug interactions affecting the efficacy of bridion
Drug-Drug Interactions Affecting the Efficacy of Bridion

No clinically relevant drug interactions have been reported with Bridion

Pharmacokinetic-pharmacodynamic simulations show that the following displacement interactions are possible:

Toremifene

The recovery to T4/T1 ratio of 0.9 could be delayed in patients who have received toremifene on the same day of surgery

Intravenous administration of high-dose flucloxacillin* and fusidic acid

The recovery to T4/T1 ratio of 0.9 could be delayed in patients who receive these products in the preoperative phase

Administration of these products in the postoperative phase (6 hours) is to be avoided

Data on file.Bridion® [summary of product characteristics]. Organon, Europe; 2008.

*Infusion of 500 mg or more.

4 03 2010 J P Mulier

drug drug interactions affecting the efficacy of other drugs
Drug-Drug Interactions Affecting the Efficacy of Other Drugs

Pharmacokinetic-pharmacodynamic simulations show that the following capturing interaction is possible:

Hormonal contraceptives

An interaction between 4 mg/kg Bridion and a progestogen could lead to a decrease in progestogen exposure, 34% of AUC, which is similar to that of a missed dose of oral contraceptive

Data on file.Bridion® [summary of product characteristics]. Organon, Europe; 2008.

AUC, area under the curve.

4 03 2010 J P Mulier

can not intubate can not ventilate
“Can not intubate / can not ventilate”
  • How frequently ?
  • Did you ever awakened your patient immediately within the first 30 minutes?
  • Conclusion:
    • It feels safe to have a drug available to bring patient immediately back to spontaneous breathing and to cancel the surgery.
    • Always have it never use it?

4 03 2010 J P Mulier

rapid sequence crush induction
Rapid sequence / Crush induction
    • Who is at Risk for aspiration?
      • Food or drank recently
      • Obstruction
      • Pregnant
      • Super obese
      • Previous bariatric surgery
  • Long procedure: high dose of NMB
    • No need for bridion or succinylcholine
  • Short procedure: high dose Rocuronium and bridion
    • Esmeron 1,2 mg/kg IBW measure TOF: bridion

4 03 2010 J P Mulier

very short and superficial blockade
Very short and superficial blockade
  • Superficial blockade is sufficient for ECT
  • Succinylcholine: 0,5 mg/kg (normal: 2 mg/kg) is sufficient
    • Relative rapid onset, within 2 minutes
    • Spontaneous recovery within 5 minutes possible
  • Rocuronium 0,15 mg/kg (normal: 0,6 mg/kg) slower onset, longer duration
    • Dose of bridion dependent on TOF
    • Neostigmine possible but side effects

4 03 2010 J P Mulier

tof monitoring
Tof monitoring
  • TOF measurement is needed
    • To justify use of bridion
    • To lower dose of bridion

4 03 2010 J P Mulier

immediate effects in morbid obese patients
Immediate effects in morbid obese patients
  • Deep breaths possible
    • Less collaps
  • Aurosal effect
    • Like Amfetamine awakening
    • Sudden muscle fiber stimulation gives aurosal
  • Patient transfers him/her self in bed
    • 50 % of cases instead of only10%
  • Spontaneous movements easier
    • Deep venous trombosis prevention

4 03 2010 J P Mulier

our results in lap rny
Our Results in lap RNY

4 03 2010 J P Mulier

slide62
Adjustable Gastric band Biliary pancreatic div DuodenalSwitch

Jejuno ileal bypass

Vertical banded gastroplasty Roux & Y Gastric bypass Sleeve Gastrectomy

4 03 2010 J P Mulier

andere vragen in de anesthesie bij morbide obesitas
Andere vragen in de anesthesie bij morbide obesitas
  • Pre operatieve voorbereiding
  • Inductie en intubatie
  • Patient positionering
  • Medicatie dosering
  • Extubatie en postoperatief beleid
  • Post op pijn behandeling

Enkele items nu belichten

4 03 2010 J P Mulier

waarom onvoldoende spierrelaxatie geven
Waarom onvoldoende spierrelaxatie geven?
  • Restcurarisatie is zeer beangstigend, slecht ademen post op, lage saturatie, hoge CO2
  • Liever geen neostigmine gebruiken omdat
    • Bradycardie tot totaal AV block
    • Bronchospasme bij asthma patienten
    • Braken en onwel gevoel post op
  • Relaxatie moet voldoende uitgewerkt zijn om te decurariseren met neostigmine
    • TOF minimum één antwoord

4 03 2010 J P Mulier

continuous deep blockade till end of surgery
Continuous deep blockade till end of surgery.
  • 3. Laparoscopy
  • Rapid awakening
  • Keep your surgeon in the OR
  • Quality surgery =
    • short surgical time
    • High volumes
  • Quality anaesthesia =
    • short turn over
    • High volumes

4 03 2010 J P Mulier

eras 1 early recovery after surgery
ERAS 1 (early recovery after surgery)
  • Halfway surgery (last 30 min)
    • Large abdomen stop esmeron infusion,
    • Small abd keep esmeron infusion till end of operation.
  • Last stapler
    • Reduce/stop remifentanyl infusion
    • Start pressure support ventilation
      • Hypercapnic PSV increases CO and BP
  • Keep inhalation conc high if small abd till end of pneumoperitoneum.

4 03 2010 J P Mulier

psv voorkomt tegenademen bij onvoldoende relaxatie
PSV voorkomt tegenademen bij onvoldoende relaxatie
  • PSV is not a valsalva effect: IAV is not changing.
  • PSV is possible during deep muscle relaxation.

PROFOUND MUSCLE RELAXATION DOES NOT DISTURB

PRESSURE SUPPORT VENTILATION.

Mulier J, Blacoe D PGA 2009

4 03 2010 J P Mulier

hypercapnia pressure support
Hypercapnia / Pressure support

J P Mulier, B Dillemans, Use of pressure support ventilation during laparoscopic bariatric surgery is possible and facilitates weaning and extubation. In:Obes Surg 2008; 18:444

J P Mulier, B Dillemans, Hypercapnic lung ventilation reduces airway pressure during laparoscopic surgery. In:Eur J Anesth 2008; 25, S44:78

4 03 2010 J P Mulier

eras 2
ERAS 2
  • Leaktest
    • High volume load
    • SAP > 140 mmHg
      • Et CO2 to 60; PSV give extra suf if tachypnoe
      • Ephedrine/phenylephrine bolus
    • dose sufenta till RR < 16
  • Last surgical stich
    • Lower PSV further, keep peep
    • Stop inhalation
    • TOF 4/4 <50% neostigmine
    • TOF < 2/4 bridion dose according to TOF and IBW
      • give bridion after patient is secured on the table

4 03 2010 J P Mulier

psv pain therapy optimalisation
PSV pain therapy optimalisation
  • Before after extra suf bolus

4 03 2010 J P Mulier

hypercapnic pressure support easier sap rise
Hypercapnic pressure support: easier SAP rise

J P Mulier (2008) Hypercapnic support ventilation during laparoscopic gastric bypass increases the cardiac output. Anesthesiology 2008 A174

4 03 2010 J P Mulier

can anesthesiology help to prevent post op bleeding yes
Can anesthesiology help to prevent post op bleeding? yes

110/57 145/78

J.P.Mulier, B Dillemans, G Vandrogenbroek, F Akin

The effect of systolic arterial pressure on bleeding of the gastric stapling during laparoscopic gastric bypass surgery.

Obes Surg 2007; 17: 1051

4 03 2010 J P Mulier

hypercapnic pressure support ventilation
Hypercapnic pressure support ventilation
  • Increases cardiac output
    • Less wound infections
  • Lowers airway pressures
  • Resp freq: morfine if too low stop PSV
  • TV: curarisation corrected by support level
  • Improves saturation per op if low
  • Rapid awakening and spontaneous breathing
    • Non surgical time between OP < 20 min
  • Less pain when awakening
    • Extra doses given during end of surgery
  • Better post op breathing
    • less post ventilation

4 03 2010 J P Mulier

eras 3
ERAS 3
  • Reversed induction technique ?
    • 50 à 100 mg propofol in bolus
  • Gastric tube suction, oral cavity clean?
  • PSV to Spontaneous, TV > 200 ml
  • Extubation beach chair if possible
    • Diep ademen, benen bewegen
    • Nooit sedativa, benzodiazepines,…
    • Voldoende pijn medicatie perop starten
  • Test: patient moet zich zelf verbedden 3 minuten na extubatie!
  • Turnover time between end surgery - incision next patient < 20 minuten.

4 03 2010 J P Mulier

conclusion
Conclusion
  • Always have Bridion available.
  • Decide when long and deep relaxation is needed till end.
  • Measure TOF ctu or at end
    • Never believe without control clinical relaxation
  • According to TOF at end operation.
    • (Nothing)
    • (Neostigmine)
    • Bridion

4 03 2010 J P Mulier

second espcop scientific meeting multidisciplinarity pordenone italy 18 sept 2010
Second ESPCOP Scientific meeting MultidisciplinarityPordenone, Italy 18 sept 2010

4 03 2010 J P Mulier

slide78
More info
  • www.publicationslist.com/jan.mulier
  • www.espcop.org

4 03 2010 J P Mulier