Anaesthetic management for Laparoscopic Cholecystectomy in a patient with COPD

Dr. Pallab Kanti NathMD AnaesthesiaSenior Resident

Department of AnaesthesiologyMedical College, Kolkata

Summary of the caseNAME : 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

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

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

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

vitals

• B.P : 138/86mmHg• PULSE : 88/min, regular, (arterial wall palpable)• RESPIRATION : 20b/m• TEMPREATURE : 36.6 c• SpO2 : 92% (room air)• Body wt :65 kg

Investigations available at PAC visit:

Blood:Hb – 13gm/dlTC:

RBC- 5.8* 10^6/ulWBC- 16,000/ulDC – 42(N), 38(L), 11(M), 9(E)

BILIRUBIN (TOTAL) 1.7 mg/ dLBILIRUBIN (DIRECT) 1.0 mg/ dLBILIRUBIN INDIRECT 0.7 mg/ dl

SGPT- 97, SGOT – 102, Alk Phos – 205

Ur/Cr, Sodium/Potassium, Blood Glucose(F/PP)- NAD

USG – Calculus Cholecystitis

ECG - NAD

CXR:• increased bronchovascular markings

• flattened hemidiaphragms(bilat) 

Plan of management:

Patient of Acute Calculus Cholecystitis

with Acute on Chronic COPD

Posted for Laparoscopic Cholecystectomy

Discussion

• COPD• Laparoscopic Surgery

Anaesthetic implications And management

COPD

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

Airspace collapse

Low V/Q

Hypoxia

Airway narrowingAlveolar hypoventilation

Hypoxia in COPD

AJRCCM 2001; 163: 283-91

Causes of Hypercapnia in COPD

Inspiratory muscle fatigue

V / QMismatch

Reduced ventilatory responseto CO2

Chronic hypoxia

Pulmonary vasoconstriction

MuscularizationIntimal hyperplasiaFibrosisObliteration

Pulmonary hypertension

Cor pulmonale

Death

Edema

Pulmonary Hypertension in COPD

Source: Peter J. Barnes, MD

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.

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.

Lung Volumes in COPD

Differences Between COPD and AsthmaParameters 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.

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

Laparoscopic Cholecystectomy

Advantages……. “minimally invasive” “ minimal access”

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)

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

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)

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

Pathophysiological effects of laparoscopy

Due to

- creation of a pneumoperitoneum

- positioning

Effects of Pneumoperitoneum...

……. created by intraperitoneal insufflation of CO2 at 1-6 lpm - Respiratory - CVS - regional blood flow - dysrhythmias - GIT - hypothermia

Respiratory Effects

1. Changes in ventilation2. Increase in PaCO23. Endobronchial intubation 4. CO2 subcutaneous emphysema5. Pneumothorax6. Gas embolism

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

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 !

Causes for PaCO2

1. Absorption from peritoneal cavity- diffusibility, area, perfusion2. V/Q mismatch; abdominal distention, patient position, mechanical ventilation, CO3. Depression of ventilation by anaesthetics if spontaneously breathing4. metabolism ( light anaesthesia, MH)5. Complications; CO2 emphysema, capnothorax, CO2 embolism, endobronchial intubation

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

Other Respiratory Effects

Endobronchial Intubation Due to cephalad displacement of diaphragm cephalad

displacement of carina Paw, SpO2 4. S/c Emphysema5. Pneumothorax6. Gas embolism

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

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

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

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

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

Hypothermia

Significant heat loss may occur

Due to – insufflation of cold gases

Temperature of gases

Rate of gas flow

Leakage through the ports etc

Positions in laparoscopic surgeries

Trendelenburg / head down; pelvic, inframesocolic surgery Reverse Trendelenburg / head up; supramesocolic surgery Lateral

Lithotomy

Effects of Positioning……

Crdiovascular

Respiratory

Nerve and other injuries

Care of eyes, iv lines, ETT etc

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

Respiratory effects; - Atelactasis - FRC, TLC - pulmonary compliance Cerebral circuln - CBF ICP ( low compliance) IOP -

HEAD UP

CVS effects; - venous return - CVP - CO - MAP Resp ; less significant changes Venous stasis ; aggravated if lithotomy

compound hemodynamic changes due to pneumoperitoneum

Nerve injury

Potential hazard

Avoid overextension arms, use shoulder braces with caution, no impingement on brachial plexus

Lower limb palsies especially peroneal neuropathy, meralgia paraesthetica, femoral neuropathy

Common peroneal n. - lithotomy

Preoperative Evaluation

Absolute C/I rare, include; - ICP ( tumor, hydrocephalus, head injury) - hypovolaemia - VP shunt - peritoneo-jugular shunt - ? Glaucoma - ? Severe CHF, severe VHD

Anaesthetic management

Calculus cholecystitis COPD

Posted for Laparoscopic Cholecystectomy

Preoperative workup

Complete hemogram Serum electrolytes Urine analysis Electrocardiogram Chest x-ray PFT including ABG ECHO

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

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

PFT predictors of increased risk

FVC < 50% predicted FEV1 < 50% predicted or < 2L MVV < 50% predicted or < 50L/min DLCO < 50% predicted RV / TLC > 50% predicted

Nunn and Milledge criteria: FEV1 < 1L, PaO2 normal, PaCO2 Normal : Low Risk FEV1 < 1L, PaO2 low, PaCO2 Normal : prolonged O2 FEV1 < 1L, PaO2 low, PaCO2 High: Ventilation

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

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

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

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.

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

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

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

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

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

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

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

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

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)

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

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

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)

Postoperative problems common with Laparoscopy Pain

PONV(40-75%)

Lung fns-diaph dysfn (residual pneumoperitoneum, phrenic n neuropraxia)

Oxygen therapy

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

Postoperative pulmonary complications

Decreased FRC Large incision Postoperative pain Splinting of the diaphragm Decreased sputum clearance Atelectasis, Pneumonia Mechanical ventilation, prolonged ICU / hospital stay Delayed ambulation DVT, PE Cor pulmonale

Complications of laparoscopy

PONV Shoulder pain Surgical instrumentation - misplacement Verress

needle, concealed hge, stomach & bladder injury CVS; collapse, vasovagal, dysrhythmias, mc dysfn, gas

embolism Pulmonary; hypoxia, hypercapnia, endobronchial

intubation, pneumothorax, pneumonia, pneumomediastinum, s/c emphysema

Nerve injuries – improper positioning ICP ; IOP DVT

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

Thank You