How to make a friend of your laparoscopic surgeon?

Transcription

1 How to make a friend of your laparoscopic surgeon? Jan Paul Mulier MD PhD Anaesthesiologist Sint-Jan Brugge, Belgium

2 2 Can we do something to improve the situation? Intraabdominal pressure? Intraabdominal volume? Workspace? Surgeon: The abdomen is flat, I have no space to operate. Anesthesiologist: your problem. The patient is sleeping enough and I am oke. Surgeon: Look at the video screen. How do you think I should work! Anesthesiologist: The patient will not tolerate higher pneumoperitoneum pressures. An experienced surgeon can handle this. Surgeon: But it is already 18 mmhg. Do you want me to change to a laparotomy? Did you give NMB by the way and why should I always have to ask that? Anesthesiologist: The patient has only one TOF response in the AP. Last time this was enough. Why not today with you? Surgeon: I don t know what one TOF response means. What I said is I can t work with you. Call your supervisor! CAPE

3 Insufficient lap workspace: how surgeons recognize it? 3 At the first insufflation with the verres needle High abdominal pressure to start > 10 mmhg. No flow is going inside. Insufficient space to reach certain areas Flat abdomen, no view Patient start to press suddenly Abdominal wall, diaphragm movements ventilator alarm Coughing or breathing against ventilator insufflator alarm IAP sudden > set pressure. PSVentilation is not noted by the surgeon! Ventilator synchrony with patient! CAPE 2013

4 4 Prediction of insufficient workspace: 1. Apple sized persons, most frequent male. 2. Women who have never been pregnant. 3. First laparoscopy. 4. Max weight at moment of surgery. 5. Abdominoplasty 6. No hip flexion possible 7. No deep NMB possible 8. Reasons to breath against ventilator

5 Example of insufficient workspace 5 1. No muscle relaxation 2. Active contraction against ventilator 3. Full muscle relaxation IAP IAV 2, PV loops with fit IAP IAP mmhg no relaxation valsalva contract relaxation 1,5 1 0,5 0-0,5 IAV liter IAP mmhg ,5 0 0,5 1 1,5 2 2, IAV liter

6 6 Example: 1,2 L versus 7,2 L Maximal NMB helps but is not sufficient alone NMB needed? Depends on the IAP used?

7 Why this difference: Patient variability 7 Inflated volume at 15 mmhg without NMB varies from 0,5 L to 10 L. Who needs NMB? Will the surgeon be comfortable? 10 8 without NMB Variability of inflated abdominal volume at 15 mmhg pneumoperitoneum inflated Volume liter patient 17 nr

8 Compliance (C) and Elastance (E) C=change in V/change in P (C= 1/E) 8 Higher insufflation pressures needed PV0 = 5 E = 4 mmhg/l Insufficient intra abdominal volume J Mulier, B Dillemans, M Crombach, C Missant, A Sels On the abdominal pressure volume relationship. The Internet Journal of Anesthesiology. 2009; 21: 1.

9 Three point calculation before after leg flexion 9

10 10 Effect of leg flexion on APVR PV0 no change E decreases PV0 4,320 = 4, ,037 = 4,91096 E 3,459 > 2,66067 Mulier JP Obes Surg ,368 > 2,577

11 Three point calculation before after deep NMB 11

12 Use of NMBA is Associated With Decreased Frequency of Poor Surgical View Conditions 1,a 12 % Patients with poor surgical view conditions Placebo n=61 P<0.001 placebo vs NMBA NMBA n=59 a In a randomized, blinded, placebo-controlled study of 120 patients undergoing radical retropubic prostatectomy, patients received an infusion of NMBA (n=59) or saline (placebo, n=61) beginning 5 minutes after fascial incision. At 15 minute intervals, the surgical field was graded from 1 (excellent) to 4 (unacceptable). Patients who were graded as having an unacceptable surgical field received rescue NMBA. NMBA=neuromuscular blocking agent. 1. King M. Anesthesiology. 2000;93:

13 Difference Between Diaphragm and Adductor Pollicis 13 Monitoring of the peripheral muscles often overestimates the degree of diaphragmatic relaxation, but is a safe predictor of recovery. Moerer O. Anasthesiol Intensivmed Notfallmed Schmerzther. 2005;40:217 The diaphragm is more resistant than the adductor pollicis to rocuronium and has a faster recovery of the twitch height. Cantineau JP Anesthesiology. 1994;81:585

14 Time difference when bolus NMB given between abdomen adductor pollices 14 Sensibility to atracurium of the lateral abdominal muscles Objective: To study the effect of atracurium on the electromyographic activity of the lateral abdominal muscles and adductor pollicis in anaesthetized subjects. Lateral abdominal muscles blockade have a faster onset and recovery than adductor pollices Kirov K et al. Ann Fr Anesth Reanim. 2000;19:

15 Solution to Both Problems: Continuous Infusion to a Deep Block 15 Deep NMB could remain in place for duration of procedure followed by rapid predictable reversal

16 BMI effect on abdominal P/V relation 16 J Mulier ISPUB 2009 Pressure volume relation is linear PV0 and E are patient determined J Mulier IFSO 2007 PV0 in mmhg Effect of BMI on PV BMI E in mmhg/l Effect of BMI on E BMI

17 Two types of android obesity 17 Subcutaneus Fat Visceral fat 25 abdominal pressure in android shape with intra visceral fat 20 IAP in mmhg IAV in liter Intra visceral adiposity Subcutaneus fat is scant and intra abdominal fat is thick and Extra visceral adiposity Subcutaneus fat is thick and intra abdominal JPMulier fat is 2012 scant.

18 Thicness of external fat 18

19 Other techniques used to improve surgical wokspace and access: Patient position Beach chair, anti trendelenburg improves access to upper abdomen even if workspace declines. 2. Higher intra abdominal pressures Max 20 mmhg possible 3. Standardisation of surgical procedure Know what to do 4. Short overstretching of abdomen at moment of difficult access. ARM procedure. 5. Weight reduction with modifast to create abdominal space.

20 Patient 3 53 years old woman with a BMI of 56 and TBW of 145 kg and a length of 1, 61 m. She was never operated before but has 4 children after which she gained a lot of weight. The WHR is 0,98 but most fat is sitting outside around the abdomen. Intermediate NMB (TOF = 3) The measured abdominal compliance is normal and around 0,4 liter/mmhg but the PV0 is +12 due to the obesity. 25 What would you do? High PV0 and normal compliance IAP mmhg APVR of patient 3 pat IAV liters

21 IAP mmhg APVR of patient 3 pat 3 pat 3 deep NMB Patient 3 PV0 = 0 E = 0.2 L/mmHg IAV liters To get a volume of 4 liters we need an IAP of /0,4 = 22 mmhg. Deep NMB allowed the PV0 to drop to 8 and the IAP to 18 mmhg. The surgeon has now plenty of space and some moments we are able to drop the pressure to 15 when he can work in 3 liters. Without deep NMB the surgeon would have only 1,4 liters at 15 mmhg IAP and would have to struggle to operate.

22 Patient 4 58 Years old man of 178 cm and 154 kg TBW. intra abdominal obesity (WHR = 1,06), He did a lot of sports 10 years ago but became inactive and gained weight. His BMI is now 48,6. No abdominal operation in the past. The measured abdominal compliance is 0,15 liter/ mmhg and the PV0 is +13 mmhg. What would you do? High PV0; non compliant abd IAP mmhg APVR of pt 4 5 pat IAV liters

23 40 35 APVR of pt4 30 IAP mmhg IAV liters pat 4 pat 4 deep NMB Patient 4 PV0 = 13 E = 0.15 L/mmHg To get a volume of 4 liters we need an IAP of /0,15 = 40 mmhg. Deep NMB drops the PV0 to 10 but the IAP to achieve 4 liters is still 36 mmhg. The surgeon might be able to work in a small workspace? At 20 mmhg, 1,5 l. Peep, anti trendelenburg reduce the space, but less peep is not an option. permissive hypercapnia with smaller tidal volumes but this has a limited value. Hip flexing rises the compliance to 0,2 and gives 500 ml at IAP of 20 mmhg. Switch to an open laparotomy, cancel the case and request the patient to loose at least 10kg body weight or request to increase shortly the IAP above 20 mmhg.

24 24 Methods to improve surgical wokspace. 1. Deep NMB NMB reduces PV0 and increases workspace with 0,5 to 2 liters. 2. Patient position Beach chair increases C and increases workspace with 0,5 liter. 3. Higher intra abdominal pressures Max 20 mmhg possible workspace increase dependent of C 4. Standardisation of surgical procedure Know what to do in less space 5. Short overstretching of abdomen at moment of difficult access. 1 liter extra possible for a short moment. 6. Weight reduction with prowell/modifast to reduce PV0. Increase with 1 liter. CAPE 2013

25 Yes we can do something move the blood brain barrier down 25 Surgeon: Now I can work and I have enough space. Anesthesiologist: the patient is OK. Surgeon: Look at the screen. The patient is relaxed and you gave me a low IAP. Anesthesiologist: the patient is now on a deep neuromuscular block with a continuous infusion. Measure to know who needs deep NMB. Surgeon: thanks, then we will end in time and we can have a drink together CAPE 2013

26 26 Your surgeon your friend? ask him to help you We learn our surgeons to handle us different? Ask not only what the anaesthesiologist can do for you, ask also what you can do for your anaesthesiologist. CAPE 2013

27 4th 27 ESPCOP meeting December 14th 2013 Crown Plaza, Burg 10 Bruges, Belgium. Does Anaesthetic technique affect outcome in the morbidly obese patient? This meeting addresses many aspects of peri-operative care for the obese patients, and amongst these will be particular focus on atelectasis, opioids, NMB and epidurals. Each lecture will discuss pathophysiology 02/06/13 and the practical consequences for us in our daily clinical work. ESA 2013 O5RC1 J P Mulier