anestesi laparoskopi
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Transcript of anestesi laparoskopi
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Anesthesia For LaparoscopicAnesthesia For L
aparoscopic
SurgeriesSur
geries
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Introduction
Laparoscopic techniques ofer shorterin-patient stay and reducedperioperative morbidity.
risks associated with individuallaparoscopic techniques or due to thephysiological changes associated withthe creation o a pneumoperitoneum.
anesthetic techniques or laparoscopicsurgery must be re!ned to anticipatethese diferences rom open surgery.
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History
traced back to the tenth century A."
Arabian physician Abulkasim#$%& ' ()(%*used re+ected light to inspect cervi,.
he term laparoscopy/ was coined by aSwedish physician 0ans 1hristian
2acobaeus
3ichard 4ollikoer o Swit5erlandpromoted the use o 1arbon dio,ide orinsu6ating peritoneum.
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Introduction
Laparoscopy introduced in 20 th Century
1975 : frst laparoscopic salpingectomy
1970 -- 0 : used !or gyne procedures
191: "emm# !rom $ermany#1st
lapappendectomy
199: laparoscopic cholecystectomy
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%&'I(I)I*(
Laparoscopy is a minimally invasive/procedure allowing endoscopic accessto the peritoneal cavity ater
insu6ation o a gas to create spacebetween the anterior abdominal walland the viscera.
he space is necessary or sae
manipulation o instruments andorgans.
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+hat all gases can ,e used
Air, oxygen, carbon dioxide, argon andhelium
ideal gas for insuation should be
nontoxic, colourless, readily soluble inblood, easily ventilated through lungs,nonammable and inexpensive
most widely used gas for insuation-CO2
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IA7 is the steady pressure within theclosed abdominal cavity.
normal values o IA7 are )-8 mm0g.
values more than (9-(: mm0gcompromises venous return.
Initial +ow ; :-& L
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>hat are the bene!ts olaparoscopy?
shortened recovery time and reducedmorbidity.
reduced manipulation o the bowel and
peritoneum@ decreased incidence opostoperative ileus@ early enteral intakeand decreased requirements or iv+uids.
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ene!ts contBdC.
laparoscopic wounds are smaller whencompared to open techniques.
complications associated withpostoperative pain and wound healingwill be minimal.
7articularly useul in obese patients inwhom open procedures would betechnically challenging.
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Are there any risks?
"amage to solid viscera@ bowel@ bladder orblood vessels due to surgical instuments.
Dascular inEuries o large vessels.
Denous gas embolism can result incatastrophic circulatory collapse.
severity depends on the volume o 19
inEected@ rate o inEection@ patient position@and type o laparoscopic procedure.
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3isks contBdC..
7nuemoperitoneum can causeventilation-perusion mismatch.
Gwell leg compartment syndromeB.
lower limb pain@ rhabdomyolysis@ andpotentially myoglobin-associated acuterenal ailure.
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.d/antages o! Laparoscopy %ay care surgery
"horter hospital stay
Impro/ed cosmesis
Less post-op ileus 'aster reco/ery
apid return to normal acti/ities
inimal pain
"mall scar
etter preser/ation o! resp !n
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%isd/antages33
ore e4pensi/e
ore operating time %icult in complicated cases
6otential !or maor
complications in
ine4perianced hand
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Laparoscopic 6rocedures
$eneral "urgery:
Cholecystectomy
.ppendicectomy
8aricocoelectomy
Hernioplasty
%iagnostic laparoscopy
Hiatus hernia repair
.dhesiolysis
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Contd3
*$:
%iagnostic tool !or in!ertility
&ctopic pregnancy
yomectomy L.8H
&ndometriosis
)horacic "urgery:
"ympathectomy
ediastinoscopy
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.naesthesia !or lap surgeries
Anaesthetic Hoals
.ccommodate surgical reuirements and allo;!or physiological changes during surgery
onitoring de/ices a/aila,le !or the earlydetection o! complications
eco/ery !rom anaesthesia should ,e rapid ;ithminimal residual e
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.naesthetic techniues
Heneral anaesthesia
6reloading ;ith crystalloid solution is recommended
6reo4ygenation %uring induction o! .naesthesia# a/oid stomach
in>ation
tracheal intu,ation ? mandatory
6L. should only ,e used ,y e4perienced L.
users ($ tu,e placement !or "tomach decompression
Catheterisation to empty the urinary ,ladder
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1onduct o anaesthesia
)he most common techniue used !orlaparoscopic surgeries is $eneralanaesthesia
protects against gastric acid aspiration#
allo;s optimal control o! C*2# and !acilitatesgood surgical access
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7re-anaesthetic check up
6neumoperitoneum stresses cardio/ascularand respiratory system more
Lee cardiac ris@ inde4 can ,e used !or
uantifcation o! cardiac ris@
'or patients ;ith heart disease thepostoperati/e ,enefts o! laparoscopy must,e ,alanced against the intraoperati/e ris@s
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7re-anaesthetic check up
In a patient ;ith poor pulmonary reser/epreoperati/ely li@e indi/iduals ;ith C*6%more e4tensi/e preoperati/e e/aluation
including 6') is ad/isa,le 6ulmonary !unction tests A6')B identi!y
patients ;ho are li@ely to e4periencehypercar,ia and acidosis
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.naesthetic 6lan
6re-operati/e assessment
)he cardiac and pulmonary status o! all patientsshould ,e care!ully assessed
6re-medication .n4iolytics
antiemetic
H2 receptor ,loc@ers
$astro-@inetic drugs
6reempti/e analgesia ;ith (".I%s
.tropine to pre/ent /agally mediated,radyarrhythmias
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7re-medication
An,iolytics
InE. =ida5olam (-9 mg iv.
AntiemeticInE. 7rometha5ine (9.8-98 mg im.
InE. ndansetron : mg iv.
InE. 3amosetron ).%mg iv.
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7re-medication contBd..
Antacids
InE. 3anitidine 8) mg iv.
InE. 7antopra5ole :) mg iv.
7ro-kinetic drugs"= 7regnancy.
InE. =etoclopromide () mg iv.
7reemptive analgesia with
JSAI"s. Atropine to prevent vagally
mediated bradyarrhythmias.
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=onitoring(.3outine 7atient =onitoringInclude Continuous C!
"ntermittent #"$%
%ulse oximetry &'pO2(
Capnography &tCO2(
)emperature
"ntraabdominal pressure
9. ptional =onitoring Include %ulmonary airway pressure
Oesophageal stethoscope
%recordial doppler
)ransoesophageal echocardiography
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=onitoring contBdC..
&o;-/olume loops
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H.A. or laproscopic surgery
bag and mask ventilation beoreintubation should be minimi5ed to avoid
gastric distension.
insertion o a nasogastric tube may berequired to de+ate the stomach-improve surgical view@ avoid gastricinEury on trochar insertion.
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Induction
6ropo!ol : 2-25 mg@g
)hiopentone : D-E mg@g
.d/antages o! propo!ol:
1 signifcantly uic@er reco/ery
2 an earlier return o! psychomotor !unctioncompared ;ith thiopental or methohe4ital
F incidence o! nausea and /omiting is mar@edlyless than other I8 anaesthetics
D ,ecause o! its pharmaco@inetics# it is superior to,ar,iturates !or maintenance o! anaesthesia
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Induction
idaGolam : 01- 02 mg@g
idaGolam is sa!e and e
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Inhalational agents
aintaining deep le/el o! anaesthesia ;ithagents li@e Halothane# Iso>urane "e/o>urane,lunt the haemodynamic response topneumoperitoneum
(itrous o4ide causing nausea /omiting iscontro/ersial ut it may distend the ,o;el# inpatients ;ith intestinal o,struction
*nce adeuate depth o! hypnosis is achie/ed#
use o! /asoacti/e drugs such as esmolol orla,etalol may ,e more appropriate to treathypertension
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=uscle rela,ants
6re/ents high intra-a,dominal and intra-thoracic pressures due topneumoperitoneum
%ecreases 6I6# there,y minimiGing e
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H.A. or laproscopic surgerycontBdC
"uccinylcholine 1-2mg@g i/
(on depolariGing muscle rela4ants
8ecuronium 00D-005mg@g or .tracurium: 05mg@g#ocuronium: 0E-1mg@g i/
3eversal ;
In (eostigmine : 005 mg@g I8
In $lycopyrolate : 001 mg@g I8
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Intra operativecomplications
InEury rom surgical instruments.
Arrythmias
1ongestive cardiac ailure cardiacarrest.
Has embolism.
7neumothora, pneumopericardium.
Subcutaneous emphysema.
Hastric aspiration.
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se o L.=.A
remains contro/ersial
)here is increased ris@ o! aspiration
%iculties are encountered ;hen trying tomaintain e
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se o 7roseal
L=A
"e/eral randomiGed controlled trials
assessing the use o! 6roseal L. A6"-L.B /sC*))# ;ith data ad/ocating the use o! 6"-L. as e
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aintenance o! .naesthesia
intermittent positi/e pressure /entilation AI668B
(ormocar,ia AFD-FmmHgB to ,e maintained ,y
adusting the minute /olume
)he use o! nitrous o4ide during laparoscopic surgery iscontro/ersial A,o;el distension during surgery and theincrease in postoperati/e nauseaB
Halothane increases the incidence o! arrhythmia
Iso>urane se/o>urane comparati/ely ,etter
e/ersal o! ( ,loc@ade
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7ressure control Ds volumecontrol..
)he use o! pressure controlled modalitiesao; pea@s#minimiGing pea@ pressures# and ha/e ,eensho;n to pro/ide impro/ed al/eolar
recruitment and o4ygenation in laparoscopicsurgery
8olume control modalities use constant >o;to deli/er a pre-set tidal /olume and ensure
an adeuate minute /olume at the e4penseo! an increased ris@ o! ,arotrauma and highin>ation pressures
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About 7MM7C
8arious studies support that a 6&&6 o! 5 cmH2* should ,e considered essential during
laparoscopic surgeries to decrease
intraoperati/e atelectasis .ddition o! titrated le/els o! 6&&6 can ,e
used to minimiGe al/eolar de-recruitment
ut must ,e used cautiously as increasing6&&6 may !urther compromise cardiacoutput
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$eneral anaesthesia
eco/ery room-6ost-op 6eriod
1Continue monitoring
26ost-op pain relie! F6ost-op shi/ering
D*2thru as@
5easures to 6re/ent pulmonaryatelectasis
E%8) prophyla4is
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Analgesia
Jp to 0K o! patients ;ill reuire opioidanalgesia at some stage perioperati/ely
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Antiemetics
Laparoscopy is associated with highincidence o postoperative nausea andvomiting.
his may worsen pain@ and e,tend theperiod o hospital admission or
patients
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Antiemetics contBdC.
Heneral measures such as de+ating the
stomach@ avoiding known emetogenicdrugs and ensuring good qualitypostoperative analgesia decreases7JD.
=ulti-modal regime such asondansetron@ cycli5ine@ andde,amethasone seems efective.
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dan@e
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*,ecti/es
to understand the principles o!anaesthesia !or laparoscopic surgery
to increase a;areness o! the ris@s o! C*2
peritonium
,enefts o! laparoscopic surgery !rompatients point o! /ie;
special considerations in geriatrics# C*6%#heart disease# pregnancy# paediatrics ando,ese patients
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Contraindications !orLaparoscopy
%iaphragmatic hernia
.cute or recent I
"e/ere o,structi/e lung disease
Increased IC6
8 ? 6 shunt
Hypo/olemia
CC'
8al/ular heart diseases
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Laparoscopy ? .nestheticissues
C*2pneumo peritoneum
%ue to patient positioning
Cardio/ascular e
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Anaesthetic management
Anaesthetic goals;
.ll the standard ;hich are set !or in patient anestheticcare should ,e !ollo;ed )hey are:
Hemodynemic sta,ility
espiratory sta,ility
.deuate muscle rela4ation
Control o! diaphragmatic e4cursion
Intra and post operati/e analgesia
Control o! 6*(8
%eep /ein throm,osis
6rotection against hypothermia
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=onitoring duringlaparoscopic surgery
ecommendation !or routine patient monitoring:
6ulse rate
Continuous &C$
Intermittent (I6
"6*2
Capnography
)emperature I.6
6.+
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ptional monitoring include
&sophageal "tethoscope
6recordial %oppler
)rans-esophageal echocardiography .rterial ,lood gas analysis
ost importantly a /igilant anaesthetist
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echnique o anaesthesia $eneral anesthesia ;ith endotracheal intu,ations and controlled /entilation is the sa!est techniue
and there!ore is recommended !or long laparoscopic procedure
.tropine is administered at the time o! induction to pre/ent ,radycardia
)he choice o! anaesthetic techniue does not seem to play a maor role in patients outcome
.deuate a,dominal and diaphragmatic muscle rela4ation is essential
apid seuence induction ;ith su4amethonium is recommended in anti re>u4 surgery
%ue to raised I.6 and increase in the mechanical /entilation pressure is reuired to achie/eadeuate /entilation(ormocar,ia is maintained ,y increasing respiratory rate
'ollo;ing induction the patient is catheteriGed to empty urinary ,ladder and nasogastric tu,e isinserted to a/oid stomach inury
Insuation >o; rate should ,e lo;# initially 1-15 Ltrmin
Jse o! nitrous o4ideA(2*B is contro/ersial !or maintenance o! anesthesia ,ecause o! concern a,outits a,ility to produce ,o;el distension during surgery and 6*(8
Halothane in the presence o! hypercar,ia can cause arrhythmia
)he position o! &) tu,e to ,e chec@ed repeatedly ,ecause o! the li@elihood o! endo,ronchialintu,atiion
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Intraoperativecomplication;
1 )rochar may cause a,dominal /essel inury# $I) per!oration#hepatic and splenic tear and omental inury 0assen minilaparotomytechniue has ,een ad/ocated !or
pneumoperitoneum creation
2 &4traperitoneal insuation o! C*2 is a commoncomplication o! laparoscopy&) C*2# 8C*2 and 6.C*2 allincreases more than e4pected
*nce diagnosed# insuation should ,e stopped and/entilation should ,e continued to ;ash out e4tra C*2
FB 6neumothora4 pneumomediastinum andpneumopericardium :-
Causes :- )respass o! gases through em,ryonic remnants #
de!ects in diaphragm# ;ea@ points in aortic and esophagealhiatus
upture o! emphysematous ,ullae
y pleural tear caused ,y surgical tear
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It can ,e diagnosed ,y
6rogressi/e hypo4emia #increasing pa; andsu,cutaneous emphysema
*,ser/ation o! a,normal motion o!diaphragm ,y laparoscopist
y auscultation
Chest 4 ray
+ith out any associated pulmonary traumathis condition resol/e a!ter 15 to F0 minsa!ter e4suation
)h d d id li
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)he recommended guidelines are as!ollo;s
"top (2*
.dust /entilation to correct hypo4aemia
.pply 6&&6
aintain close communication ;ith surgeon
./oid thoracocentesis unless necessary
In case o! pneumothora4 !rom rupture o! pree4isting ,ullae #6&&6 must not ,e applied andtharococentesis is mandatory
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C.& '* 6&8&()I*( 6*") *6&.)I8&
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C.& '* 6&8&()I*( 6*") *6&.)I8&6*L&"
*2 administration !or couple o! hours topre/ent al/eolar hypo4ia as C*2 e4cretion
continues &nergetic care !or pre/ention o! sic@ness
must ,e ta@en as 6*(8 can eopardiGe allthe ,enefts o! laparoscopy andanesthesiologist gets total ,lame
6roper ;arming o! patient
.ttention must ,e paid !or pain relie!
'J)J& )&(%"
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'J)J& )&(%":
I(&) $."&" : Jse o! inert gases li@e helium #argoncan reduce hypercar,ia ,ut other changes due toincreased I.6 remain same "ince solu,ility o! thesegases is lo;# there is al;ays a chance o! gas
em,olism
$."L&"" L.6.*"C*6M:Here the peritoneal ca/ity ise4panded ;ith a !an retractorthis techniue a/oidshemodynamic and respiratory repercussions6ostoperati/e 6*(8 and port site metastasis arereduced)his thing is /ery appealing in se/ere cardiacand pulmonary diseases%isad/antages are poorsurgical site and increased technicaldicultyCom,ined this techniue ;ith lo; I.6AN5mmo! HgB is an interesting prospect
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"ummary
%espite multiple ad/antages#Laparoscopy is not a synonym !or ris@!ree operation )he death rate duringlaparoscopic surgery is 01 to 1 per
1000 cases .nesthesiologist must ,ea;are# a,le to detect and managethose li!e threatening complicationCapnography is one o! the mostimportant tool to tac@le thesecomplication and e/ery one should@no; ho; to interrelate &)C*2 ;ithother important fndings
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C*2 i th i ti !
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C*2 remains the insuation gas o!choice ,ecause o! ?
Its readily a/aila,ility
Lo; cost
. high ost;ald ,lood gas partion co ecientma@es it highly solu,le in ,lood "o the gasem,olism is rare
(on com,usti,le rapidly ,u
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