Anesthesia for Laparoscopic Interventions.ppt

1、Anesthesia for Laparoscopic Interventions,Peter Biro Department of Anesthesiology University Hospital Zurich peter.birousz.ch,The Good“,Advantages,Better cosmetic results Less pain, less analgesics required Shorter in-hospital stay Less complications (outcome?) Better pulmonary function (in particul

2、ar in obese patients) Fast recovery, better comfort,Cholecystectomies in my Hospital,Cholecystectomies in my Hospital,Cholecystectomies in my Hospital,Cholecystectomies in my Hospital,Surgeon,Urologist,Gynecologist,Diagnostic Intestinal Herniotomy Liver Spleen Fundioplication Cholecystectomy Esophag

3、us Axillar lymphonodes Gastric banding Adrenalectomy Parathyreoidectomy,Diagnostic Nephrectomy Kidney cysts Prostatectomy Varicocele Lymphadenectomy Testicular descensus,Diagnostic Tubar ligation Adnexectomy Ovarectomy Lymphadenectomy Endometriosis Myomectomy Axillar lymphonodes,What about the Anest

4、hetist?,General Anesthesia & Perioperative maintenance of vital functions .and comfort,The Bad“,Mechanical Effects of Pneumoperitoneum,Elevated intra- and retroperitoneal pressure Diaphragma displacement to cranial Elevated intrathoracic pressure Increase of airway pressure Decrease of total respira

5、tory compliance Gas embolism (risk of),Effects on Pulmonary Function,Change of FEV1 (post- vs. preoperative) 55% 30% Duration till return to baseline FEV1 9.5 days 5 days FRC on 1st postoperative day 20% 34% PEF25-75% on 2nd postoperative day 50% 25% Confirmed post operative atelectasis (X-ray) 90%

6、40%,Open vs. Laparoscopic Cholecystectomy,Other Effects of Pneumoperitoneum,Resorption of CO2 (hypercarbia, acidosis) Increase of PCO2 (arterial and end-tidal) Acidosis Increase of lactic acid Hormonal changes (catecholamines, vasopressin) Aggravation or improvement of side effects due to posture .b

7、ut oxygenation remains basically unchanged,Hemodynamic Effects of Pneumoperitoneum,Increase of atrial filling pressures (right: CVP, left: wedge pressure) Increase of heart rate Increase of both, systemic and pulmonary vascular resistance Increase of both, arterial and pulmonary blood pressure Cardi

8、ac output and intrathoracic blood volume show unconsistent changes in both directions,Hormonal Effects of Pneumoperitoneum,Increase of. Vasopressine Dopamine Adrenaline Noradrenaline Renine Cortisone sympatho-adrenergical stimulation, stress“ metabolism,Example for Overlaping Effects,40,60,80,100,12

9、0,MAP,HR,SVR,40,60,80,100,120,40,60,80,100,120,mmHg Beats/min Dyne/s/cm-5/20,CO2 Homeostasis and Pneumoperitoneum,CO2 uptake in 2 phases: Initially fast resorption for app. 30 minutes Followed by equlibration on higher level (30% of baseline) If spontaneous ventilation possible increase of alveolar

10、ventilation V/Q mismatch leads to arterio-alveolar CO2 difference. invasive blood gas measurements mandatory in high risk patients (ASA III),Patients at Cardial Risk,Due to. acute elevated afterload and sometimes decreased preload (head up posture) one must aplly: invasive arterial blood pressure me

11、asurement In case of cardial insufficiency / pulmonary hypertension: TEE, Swann-Ganz catheter IAP not above 10 mmHg,or even better .arrangement for or transition to open surgical procedure in neutral horizontal position,Patients at Cardial Risk,Measures to improve situation (before transition to ope

12、n surgical approach). Reduction of afterload with vasodilators Carefull fluid replacement (under continuous TEE controll) Application of positive inotropic and vasodilating agents such as dobutamine or phosphodiesterase inhibitors Immediate measures in case of dramatic cardial deterioration: reversa

13、l of pneumoperitoneum (stop CO2 inflow, deflate abdomen) reversal of head down position to neutral or slightly elevated,Organ Perfusion and Pneumoperitoneum,Decrease of. gastrointestinal blood flow (in particular with IAP 15 mmHg) renal blood flow Increase of. cerebral blood flow (cave: patients wit

14、h elevated intracranial pressure),Pneumoperitoneum and Pregnancy,Increase of intrauterine pressure Decrease of uterine blood flow Decrease of fetal blood pressure,Consequences have to be evaluated on an individuall scale. Eventually consideration of open surgical procedure in neutral horizontal posi

15、tion,Pneumoperitoneum and Pregnancy,Cholecystectomy is the most often perfomed non-obstetric surgical intervention in pregnancy Meanwhile 50% are performed in laparoscopic mode However,. surgery before 20th week of gestation bears elevated risk for preterm birth No evidence for difference in malform

16、ation frequency in open vs. laparoscopic surgery,Actually there is no general contraindication for laparoscopic surgery in pregnancy,Pediatric Surgery,Since the nineties laparoscopy usual for neonates and toddlers Hemodynamic effects are more pronouncedTherefore. limit IAP to 8 mmHg table positionin

17、g angle not exceeding 15 avoid vagal reflexe (bradycardia) not recommended for emergency operations,Morbid Obesity,Higher rate of complications (+18%) Longer in-hospital stay (4-5 days more)However, laparoscopic procedures have strong advantages. less problems with wound healing less tendency for bu

18、rst abdomen early mobilization,CO2 Homeostasis and Pneumoperitoneum,Amount of CO2 uptake is dependent on intraabdominal pressure (IAP) and duration of pneumoperitoneum With IAP 10 mmHg hyperkapnia is unlikely After discontinuation of pneumoperitoneum fast reversal of hypercarbia even without forced

19、hyperventilation,Complications,Aspiration of gastric content Intraoperative occurrence up to 6% in 50% of cases reflux of gastric acid Consequences gastric tubing tracheal intubation (no laryngeal mask or similar supraglottic devices),Complications,Secondary unilateral bronchial ETT displacement Eti

20、ology diaphragma elevation airway shifts upwards while ETT is fixed at teeth level Consequences ETT advancement not deeper than 20 cm carefull checking and re-checking of bilateral ventilation (in case of doubt fiberbronchoscopy),Complications,Hypothermia not less than in open surgery use patient wa

21、rming devices as usual Smoke resorption carbon monoxide (CO) poisoning possible check blood gases regularly Surgical emphysema due to improper CO2 insuflation check for airway obstruction Vascular injury and bleeding may occurr during insertion of scope avoidance by muscular relaxation,Complications

22、,Pneumothorax stop CO2 inflow, deflate abdomen, insert thoracic drainage Pneumomediastinum typical for surgery of diaphragma or esophagus differencial diagnosis to pneumothorax or gas embolism necessary risk of pericardial tamponade diagnosis to be made with echoecardiography,Complications,Gas (CO2)

23、 embolism Etiology intravasal gas insufflation (CO2 voulme 5x larger than for air) Symptoms fast decrease of PetCO2 decrease of oxygen saturation (SpO2) without change of airway pressure Hypotension Cardiac arrhytmia Precordial mill wheel sound“ Measures stop CO2 inflow, deflate abdomen, left tilt p

24、osition, aspiration of gas via central venous line,Side Effects,Postoperative pain positive correlation to level and duration of IAP and intraabdominal pH projection into the shoulder due to irritation of diaphragm sometimes free interval up to 24 hours duration up to 3-4 days Therapy multi modal an

25、algesia (combination of different drugs and application modalities according to standardized protocolls),Side Effects,Postoperative Nausea and Vomiting (PONV) more in laparoscopic than in open surgery (in particular gynecology) young females 30 years non smokers early pregnancy first phase of menstruation amount of CO2 uptake Therapy corticoids, 5-HT3 antagonists, dehydrobenzperidol,Schulte Steinberg H., Euchner Wamser I., Zalunardo M.P. Ansthesie fr laparoskopische Eingriffe. Anaesthesist 1999, 48: 755-768,