Anesthesia for Laparoscopic And Robotic Surgery Flashcards
What is a pneumoperitoneum?
installation of air or gas into the peritoneal cavity under controlled pressure
What is the ideal gas for a pneumoperitoneum?
The ideal gas for abdominal insufflation is capable of increasing working and viewing space while being inexpensive, colorless, not flammable, inexplosive, easily removed by the body, and completely nontoxic to patients undergoing laparoscopic procedures.
CO2 has become the gas of choice in most instances because it possesses these properties with minimal risk of air embolization
What is the gas of choice for pneumoperitoneum?
CO2
Cardiovascular Effects of the pneumoperitoneum include:
Increases in mean arterial pressure (MAP), systemic vascular resistance (SVR), and heart rate sustained over the insufflation duration have been demonstrated
In some patients, the peritoneal stretch that coincides with the induction of the pneumoperitoneum may stimulate a vagally mediated bradycardia
During abdominal insufflation, which is the causative factor for hemodynamic changes?
Compression of the intraabdominal vessels and release of neuroendocrine hormones (i.e., vasopressin and renin
The increases in MAP and SVR are observed regardless of whether the pneumoperitoneum is created under low pressure ____ or high pressure _______.
The increases in MAP and SVR are observed regardless of whether the pneumoperitoneum is created under low pressure (12 mm Hg) or high pressure (20 mmHg).
Vagally mediated bradycardia due to peritoneal strech can be relieved by:
Releasing the pneumoperitoneum and then preventing it by ensuring that insufflation pressures remain under 16 mm Hg. If this is insufficient, treatment with anticholinergics such as glycopyrrolate or low-dose atropine may be warranted
Pneumoperitoneum pressures and effects
Gas embolism is defined as
The direct entrainment of air and/or other medical gases, such as carbon dioxide, into the arterial or venous system.
Signs and symptoms of a significant gas embolism in the anesthetized patient include
An acute decrease or loss of end-tidal partial pressure of carbon dioxide and an increase in end-tidal nitrogen if air is entrained, which is accompanied by hypotension and/or hypoxia that cannot be explained by deep anesthesia or hypovolemia
Dysrhythmias, severe hemodynamic instability, and cardiovascular collapse can occur when large volumes of gas are entrained, especially in patients with impaired cardiovascular function and minimal cardiac reserve.
Large gas embolisms result in
obstruction of the right ventricle or pulmonary artery, resulting in a precipitous drop in cardiac output
What is the most sensitive diagnostic technique for the detection of gas emboli?
Transesophageal echocardiography
Transesophageal echocardiography can identify emboli as small as
0.02mL/kg
During a gas emboli Changes in Doppler sounds and increases in pulmonary artery pressures will occur with volumes of
0.5 mL/kg of gas.
During gas emboli when the “classic mill wheel murmur” is audible, gas volumes of___ mL/kg or more have been entrained, and significant hemodynamic instability is present.
2mL/kg
Management of gas embolism
Gas embolism box 34.6 S/S and Tx
Enhance Recovery After Surgery (ERAS)
Enhance Recovery After Surgery (ERAS) Pre-op, Intra-op, and Post-op Recommendations
