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Laparoscopy in COPD: Anaesthesia
1. Anaesthetic management for
Laparoscopic Cholecystectomy
in a patient with COPD
Dr. Pallab Kanti Nath
MD Anaesthesia
Senior Resident
Department of Anaesthesiology
Medical College, Kolkata
2. Summary of the case
NAME : Mr. Pulak Dutta
AGE/SEX : 62 YRS/ MALE
Address : LP. 64/2, Birati
Occupation : Carpenter
Education :Studied upto Class X
DATE OF ADMISSION : 25/11/15
3. Chief complaints
• Pain abdomen off and on for last 4 months
• Fever for last 3 days
• Three episodes of vomiting on the day of admission
4. Initial Management
Initially Patient was seen by local physician
Diagnosed as a case of acute cholecystitis with cholelithiasis
Patient received antibiotics (ciprofloxacin/metronidazole),
analgesics (PCM, Drotaverine), Pantoprazole and Ondansetron
Later patient was referred to Medical College, Kolkata for further
management
In Medical College, Patient was continued on the conservative
management and planned for Laparoscopic cholecystectomy
5. Comorbidity
Cough and wheeze: off and on for last 5 years
Further questioning revealed:
Smoker for last45 years
20 /day, now reduced to ~10
Increased cough, expectoration from last week
currently taking Salbutamol puffs, ipravent puffs and budenoside
inhaler (local physician consultation)
Can climb 2 flights with difficulty – gets breathless
Clinically RS : barrel chest, wheeze and ronchi present
CVS NAD on examination
12. Pathophysiology of COPD
Increased mucus production and reduced
mucociliary clearance - cough production
Loss of elastic recoil - airway collapse
Increase smooth muscle tone
Pulmonary hyperinflation
Gas exchange abnormalities - hypoxemia
and/or hypercapnia
16. Polar forms of COPD:
CHRONIC BRONCHITIS
Chronic bronchitis is defined by a productive cough on
most days for at least three months for at least two
consecutive years and which cannot be attributed to
other pulmonary or cardiac causes.
17. Polar forms of COPD:
EMPHYSEMA
Emphysema is characterised by destruction of alveolar
walls, resulting in abnormal enlargement of airspaces
and loss of lung elasticity, with consequent obstruction
of peripheral airways.
19. Differences Between COPD and Asthma
Parameters COPD Asthma
Onset Mid-life Early in life (often
childhood)
Symptoms Slowly progressive Vary from day to day and
peak in the night/early
morning
History Long smoking history or
exposure to smoking and
bio-mass fuel
History of allergy, rhinitis
and/or eczema.
Inflammatory cells Neutrophils Eosinophils
Airway
hyperresponsiveness
Absent Present
Airflow limitation Largely irreversible
usually < 15% or 200 ml
change
Largely reversible
usually > 15% or 200 ml
change.
20. Extrapulmonary comorbidities in COPD
Commonly seen
Weight loss
Nutritional abnormalities
Skeletal muscle dysfunction
Increased risk of
Myocardial infarction
Angina
Osteoporosis, bone fractures
Respiratory infection
Depression
Diabetes
Sleep-disorders
Anemia
Glaucoma
Common consequences
RVH
Cor pulmonale
22. Reduced stress response
Reduced acute phase reactants; CRP, IL 6
Reduced metabolic response; N2 balance & immune
function better preserved
Not much reduction in endocrine response; Plasma
cortisol, catecholamines similar (pain, discomfort from
peritoneal stretch, hemodynamic dist, vent changes)
23. Reduced pain and analgesic
requirements
Less acute pain
Shorter duration of pain
Less analgesic consumption
Smaller incision; less superficial trauma
More of visceral pain, shoulder tip pain
24. Decreased postoperative respiratory
dysfunction
Less pain
Less atelactasis, less respiratory infection
Diaphragmatic function impaired but less than after
laparotomy
Pulm fn less impaired (30-38% less than lap)
25. Pneumoperitoneum
• Abdominal insufflation w/ CO2, helium, nitrous oxide, or
oxygen to ~ 15 mmHg
– Normal Intra-abdominal pressure (IAP) < 5 mmHg
• CO2 most commonly used gas.
– Noncombustible = safe to use with electrosurgical devices
– Solubility in blood and reactivity w/ soluble buffering systems
minimize the risk of gas emboli (
)
• Systemic absorption thought to be facilitated by CO2
specific widening of inter-cellular junctions in peritoneum
buffering of CO2 as above Systemic Acidification
27. Effects of Pneumoperitoneum...
……. created by intraperitoneal insufflation of
CO2 at 1-6 lpm
- Respiratory
- CVS
- regional blood flow
- dysrhythmias
- GIT
- hypothermia
28. Respiratory Effects
1. Changes in ventilation
2. Increase in PaCO2
3. Endobronchial intubation
4. CO2 subcutaneous emphysema
5. Pneumothorax
6. Gas embolism
29. Changes in Ventilation
compliance (30-50% )
thoracopulmonary
in FRC (elevation of
diaphragm)
airway pressure
changes in distribution of
ventilation & perfusion
*IAP 15 mmHg exerts pressure 50 kg
on diaphragm
30. Increase in PaCO2
s to reach plateau in 15-30 mins
depends on IAP
EtCO2 plateaus after
25-30 mins
Any rise after that
– search for cause !
31. Causes for PaCO2
1. Absorption from peritoneal cavity- diffusibility,
area, perfusion
2. V/Q mismatch; abdominal distention, patient
position, mechanical ventilation, CO
3. Depression of ventilation by anaesthetics if
spontaneously breathing
4. metabolism ( light anaesthesia, MH)
5. Complications; CO2 emphysema, capnothorax,
CO2 embolism, endobronchial intubation
32. 10-25% in alveolar ventilation for normocapnia
Remains unchanged if under LA ( MV s)
EtCO2 is an imperfect index of PaCO2 if dead space
ventilation ( PaCO2 may be high despite normalization of
EtCO2 by increasing MV)
In ASA class II/III pts - poor correlation b/w PaCO2 &
EtCO2
33. Other Respiratory Effects
Endobronchial Intubation
Due to cephalad displacement of diaphragm cephalad
displacement of carina Paw, SpO2
4. S/c Emphysema
5. Pneumothorax
6. Gas embolism
34. Cardiovascular Effects
Peritoneal insufflation to IAP > 10 mmHg (in normal pts) for
significant alterations in hemodynamics
Biphasic effect on Cardiac Output
Initial transient due to splanchnic compression (IAP<15)
Then CO (10-30%)
Due to
- venous return
To attenuate
- Fluid loading pre &
intraoperatively
- Head low before insuffln
- Pneumatic compression
- Elastic bandage legs
35. SVR
Due to;
- direct compression abdominal aorta & abdominal
organs
- Reflex symp response to CO
- Release of neurohumoral factors vasopressin,
catechols, renin-angiotensin
PVR
HR slight , unchanged
arterial BP despite CO
36. IntraAbdominal Pressure
Pooling of
blood legs
caval
comp
Vn
Res
I/thoracic pr peritoneal
recs stimn?
vasc res
aorta &
abdal
organs
Neurohumoral factors
Venous
return
inotropism? SystemicVasc Res
Cardiac Output Arterial pressure
37. Cardiac arrhythmias
Reflex ’s in vagal tone sudden peritoneal stretch
bradycardia, arrhythmias, asystole
- Stop insuffln, atropine, deepen anaesthesia
PaCO2 ? May not correlate
Use of halothane
Pts with cardiac disease
Gas embolism
hypoxia
38. GIT Effects
Due to intra abdominal pressure ?? ? risk
of aspiration
BUT
Changes in LES tone maintenance of pressure gradient
across GE junction risk of regurgitation
Head down position prevents regurgitated material from
entering the airway
39. Hypothermia
Significant heat loss may occur
Due to – insufflation of cold gases
Temperature of gases
Rate of gas flow
Leakage through the ports etc
40. Positions in laparoscopic surgeries
Trendelenburg / head down;
pelvic, inframesocolic surgery
Reverse Trendelenburg / head up;
supramesocolic surgery
Lateral
Lithotomy
41. Effects of Positioning……
Crdiovascular
Respiratory
Nerve and other injuries
Care of eyes, iv lines, ETT etc
42. HEAD DOWN
CVS effects;
- CVP
- CO
- Systemic vasodilation & bradycardia due
to baroreceptor reflex to hydrostatic pr.
- transmural pressure in pelvic viscera
blood loss, gas embolism
49. Indications for PFT:
Patients in whom risk of surgery is high
Patients needing specialised postop respiratory care
Surgery should not be denied on the basis of abnormal
PFT
50. Assessment of Severity
(Spirometry)
Mild Moderate Severe Very severe
FEV1/ FVC
<70%
FEV1
>80%
FEV1/ FVC
< 70%
FEV1
50% - 80%
FEV1/ FVC
<70%
FEV1
30% - 50%
FEV1/ FVC
<70%
FEV1< 30%
or chronic
respiratory
failure or right
heart failure
52. Preoperative Preparation
Stop smoking
Improves mucociliary function, decreases sputum production and
airway reactivity : 2 months
Reduce CO levels : 12 hours
Bronchodilators
Control of infection
Chest physiotherapy, hydration
Familiarise patient with deep breathing exercises and respiratory therapy
equipment that are likely to be used postop
Improve oxygenation
Steroids
Diuretics, digitalis
53. Smoking cessation & time course
Time course Beneficial effects
12 – 24 hours CO & nicotin levels
48 – 72 hours COHb levels normalise & airway
function improve
1-2 weeks Sputum production
4 – 6 weeks PFTs improved
6 - 8 weeks Immune function & drug metabolism
normalise
8 – 12 weeks Overall postop morbidity
54. Perioperative steroids? Which patients?
What are equivalent doses of steroids?
Long-term steroids >10 mgs prednisolone daily
Pts on steroids >10 mgs daily, in last 3 months.
Pts on high dose inhalation steroids
Prednisolone 5 mgs is equivalent to
Betamethasone 750 microgms
Cortisone acetate 25 mgs
Dexamethasone 6 mgs
Hydrocortisone 20 mgs
Methylprednisolone 4 mgs
55. Recommendations for perioperative steroids
Dose Surgery Recommended dose
<10
mg/day
Minor /
Moderate /
Major
Additional steroid cover not required (assume
normal HPA response)
>10
mg/day
Minor surgery 25 mg of hydrocort at induction & normal
medications post-op
>10
mg/day
Moderate
surgery
Usual dose pre-op & 25 mg hydrocort IV at
induction then 25 mg IV TDS for 1day then
recommence pre-operative dosage
>10
mg/day
Major surgery Usual dose pre-op & 100 mg hydrocort at
induction then 100 mg IV TDS for 2-3 days.
56. Monitoring
HR, continuous ECG
Intermittent BP
EtCO2
SpO2
Temp
Intra abdominal pressure
Airway pressure, Expired tidal and minute volume
IBP, ? CVP,? PCWP – patients with heart disease
TEE - pts with more severe heart disease
ABG- as Δa-EtCO2 - pts with severe heart disease
Hourly urine output
57. Choice of Anaesthesia
General Anaesthesia
Allows control of ventilation, excellent muscle
relaxation
Ensures oxygenation and CO2 elimination
IPPV overcomes decrease in lung compliance,
increased resistance and decreased FRC
Comfort to patient, prolonged procedures
58. GA specifics for Laparoscopy
Preloading prior to pneumoperitoneum
Decompress stomach / bladder
Smooth induction and release of pneumoperitoneum
Keep IAP as low as possible; IAP < 12- 15 mmHg
Positioning; head low prior to insufflation
Minimise tilt < 20°; slow
59. Ctd……..
Check ETT after positioning
Adjust ventilation to maintain EtCO2 about 35 mm Hg by
MV by 15-25%
Adequate anaesthesia depth
Omission of N2O may improve surgical condns
Consider use of vasodilators like nicardipine, 2 agonists,
remifentanil
60. Regional anaesthesia
Avoids risk of bronchospasm due to intubation
Excellent intraoperative and postoperative analgesia
Problems
Spontaneous ventilation may lead to hypoventilation
Hypercarbia and acidosis can increase PVR
Inadequate muscle relaxation, coughing / bucking
High levels of spinal / epidural block
Increase parasympathetic tone and cause bronchospasm
Decrease ERV by ~50%, detrimental for active expiration
Hypotension
Prolonged procedure, patient discomfort, shivering
Heavy sedation may be worse than light GA
61. My choice for this case
GA combined with epidural analgesia
All benefits of GA
Excellent analgesia with epidural
Reduced requirement of muscle relaxants
Lower risk of hypotension
Postoperative analgesia without excessive systemic
narcotics
May facilitate early ambulation
Better performance of respiratory therapy manoeuvres
May reduce postoperative pulmonary complications
May reduce risk of DVT
62. Premedication
Steroid hydrocortisone 100mg iv
Salbutamol 2 puffs, ipratropium 2 puffs, budenoside 2
puffs before sending to OT
Atropine
Decreases airway resistance
Decreases secretion-induced airway reactivity
Decreases bronchospasm from reflex vagal stimulation
But can cause drying of secretions, mucus plugging
Small dose of benzodiazepine acceptable
Avoid H2 receptor antagonists
63. Induction
Avoid thiopentone
Thiobarbiturates may cause histamine release
Prefer oxybarbiturates (methohexitone)
Airway instrumentation or other stimulation under light thiopentone
anaesthesia may provoke bronchospasm
Ketamine
Tachycardia and HT, may increase PVR
Agent of choice in unstable / wheezing patient
Propofol
Offers marked protection from bronchospasm
But watch for hemodynamic compromise
Agent of choice in stable patient
64. Intubation
NDMR – vecuronium, rocuronium preferred
IV lignocaine prior to laryngoscopy and intubation
Narcotic
Deep plane of anaesthesia prior to intubation
LMA avoids tracheal stimulation (LMA Proseal – Laparoscopy)
65. Maintenance
IPPV
Muscle relaxant
Avoid atracurium, mivacurium
Prefer Vecuronium, pancuronioum, rocuronium
Inhaled agent
Halothane most potent bronchodilator (< 1.7 MAC)
Isoflurane comparable at higher MACs
Irritant smell may provoke bronchospasm
Narcotic
Fentanyl
Morphine, pethidine may cause histamine release
66. End of Anaesthesia
Any problems anticipated during reversal?
Neostigmine may provoke bronchospasm
Atropine 1.2-1.8mg or glycopyrrolate 0.6mg before
neostigmine
Extubation : deep or late, awake?
Deep extubation may reduce chance of bronchospasm
But in this case delayed extubation may be preferred
May require a period of postoperative ventilation
Awake, obeying commands
Sustained head lift
Adequate gas exchange
67. Postoperative management
Admit patient into a ICU if ventilated
HDU if not ventilated
Controlled Oxygen therapy
Provide good postoperative pain relief
Postoperative respiratory therapy
Encourage lung inflation manoeuvres
Ambulate as early as possible to prevent pulmonary
morbidity and other complications (such as DVT and
PTE)
68. Postoperative problems common with
Laparoscopy
Pain
PONV(40-75%)
Lung fns-diaph dysfn (residual pneumoperitoneum,
phrenic n neuropraxia)
Oxygen therapy
69. Pain relief
More visceral than somatic pain
Higher IAP –more pain
LA infiltration- intraperitoneal, port site
Shoulder pain - careful evacuation of residual CO2
Preoperative NSAIDs
Intra & post operative opioids
Use multimodal analgesia
72. Subcutaneous emphysema;
extraperitoneal insufflation – accidental/ intentional
Pneumomediastinum, pneumopericardium;
Pneumothorax ;
Capnothorax
-Embryonic channels/ peritoneopleural ducts right side
- Defects in diaphragm,weak points in oesophageal & aortic
hiatus
- Pleural tears at level of GE junction left side
- Rupture of emphysematous bullae Pneumothorax