Operations

Question 1

What are the considerations when anaesthetising a patient for a complex laparoscopic ultra-low colonic resection? 2017B05 - 36.2%

Answer 1

Complex Surgery
Long Case
Steep head down + Pneumoperitoneum

Preop suitiablily - morbidy obesity significant CVS/Resp disease to tolerate

Airway - check positioning once head down - risk of ETT to migrate endobronchial.
Long case so risk of airway oedema, would level out when possible, and do leak test prior to extubation

Breathing - Steep Head down + pneumoperitoneum -> increased intraabdominal pressure , decreased FRC, increased airway pressure, V/Q mismatch.
I would use paralysis and monitor with TOF aim <2
Lung protective ventilation - 6ml/kg , titrated PEEP, recruitment manoeuvre as required.

Circulation - Increase in afterload, and venous return, if cardiac disease slow change to position

CNS - steep head down and increased ICP –> risk post op confusion - inform patient, level out, no neck ties.

Access - usually arms tucked so limited
- 2 x IVC + IAL as long case - can take gases , minimise pressure injury for non invasice

Temperature - temp probe - 36-37

Post op - confusion in PACU, consider HDU depending on surgery .

Question 2

Discuss your perioperative management of a patient with carcinoid syndrome presenting for small bowel resection

Answer 2

Carcinoid tumour derived from enterochromaffin cells - neurosecretory granules containing
VASOACTIVE SUBSTANCES
histamine, serotonin, dopamine, substance P, prostaglandins

Carcinoid Syndrome ~10% carcinoid - flushing bronchospasm . hypo/hypertension

Biggest concern is Right heart disease with fibrosis of thickening of endocardium - mixed tricuspid and pulmonary valve disease

PREOP
CVS investigation, ECG, TTE, functio nal assessment - evidence of right heart disease

Octreotide infusion - commence 12-24 hrs prior to surgery - somatostatin antagonistic effect and inhibits splancnic blood flow. @50mcg/hr

ECG- RVH, UEC (diarrhorea), FBC anaemia,

Intra op
Concern is haemodynamic instability especially when handling the tumour

Induction - Analgesia/ Stable

Arterial Line and Central Line.

Avoid morhpine, actracurium

In the event of instability the recommendation is for octreotide boluses. 25-50Ug

Noradrenaline can have unpredictable effects as it can promote activation of kallikrien –> bradykinin release

Consider Vasopressin

Post op
HDU / ICU - risk of instability post op especially if remnant tumour 48hrs