INDIRA GANDHI MEDICAL COLLEGE,SHIMLA

INTRODUCTIONProfessor Department Of Anaesthesia

M.D.,D.A.(Gold Medal),Dip.Hosp.Admin,PGDDM(Disaster

Management),Chairman Disaster Cell-IMA,HP

THORACIC EPIDURAL-A PRACTICAL ALTERNATIVE

TO GA IN UPPER ABDOMINAL

LAPROSCOPIC SURGERY

AREAS

.History Of Laproscopic SurgerySpecial Considerations For laproscopic Surgeries.Problems With GA.Thoracic- Epidural.Considerations In Thoracic Epidural.Technique.Advantages.ComparativeEvaluations

.

HISTORY OF LAROSCOPIC SUGERY• 1902• Georg Kelling, of Dresden, Saxony, performed the first laparoscopic procedure on dogs.• • 1910• Hans Christian Jacobaeus of Sweden, reported the first laparoscopic operation on humans.• • 1980• Patrick Steptoe from England, started to perform laparoscopic procedures in the operating room under sterile

conditions.• • 1982• The first solid state camera was introduced and this was the start of 'video-laparoscopy'.• • 1987• Phillipe Mouret performed the first video-laparoscopic cholecystectomy in Lyons, France.• • 1994• A robotic arm was designed to hold the laparoscope camera and instruments.• • 1996• The first ever live broadcast of laparoscopic surgery via the Internet was performed

BENIFITS OF LAPROSCOPIC SUGERY:

summarized as :• 1)Minimal inscision• 2)Less metabolite derangements• (studies have confirmed the reduced

metabolite derangement by measuring interlukin 6 level and c reactive protein ).

• 3)Reduced adverse effect • 4) Postoperative pulmonary function test

BENIFITS OF LAPROSCOPIC SURGERY-II:

• 5)Less postoperative ileus due to less tissue handling ,so oral feeding can be started early

• 6)Less postoperative pain .• This all leads to early ambulation .• Shorter hospital stay .• Early return to work and normal activity .

SPECIAL CONSIDERATION FOR LAPROSCOPIC SURGERY:

• Laparoscopic surgery,although enjoying ever increasing popularity present view anaesthetic challenges because of

• Carbondioxide insufflation to produce pneumoperitoneum

• Position of the patient that is trendelenburg and reverse trendelenburg

CHANGES DUE TO PNEUMOPERITONEUM

2l/Min. • pressure over the diaphragm is almost 50 kg.

( in trendelenburg position at an IAP of 15mmhg ) results:

• Decreased Tidal and so Minute volume• Decreased FRC• Increased PAW• Increased risk of barotrauma during IPPV

ANAESTHETIC CONSIDERATIONS:

• Hemodynemic stability• Respiratory stability• Adequate muscle relaxation• Control of diaphragmatic excursion• Intra and post operative analgesia• Control of PONV• Deep vein thrombosis• Protection against hypothermia

MONITORING CONSIDERATIONS:

Routine patient monitoring:• Pulse rate,Continuous ECG,Intermittent

NIBP,SPO2,Capnography,Temperature,IAP,PAW OPTIONAL MONITRING:• Esophageal Stethoscope• Precordial Doppler• Trans-esophageal echocardiography• Arterial blood gas analysis• Most importantly a vigilant anaesthetist

METABOLIC PROBLEMS• PCO2 reaches plateau 15 to 30 min .Rise of PCO2 due to

factors which also contributes to raise PCO2 are :• Va/Q mismatch – increased physiologic dead space-• abdominal distension,position of patient (steep head down)• Controlled mechanical ventilation • Reduced cardiac output• Increased metabolism Insufficient plan of anesthesia• Transfusion of more glucose containing fluid• 3. Depression of ventilation by anesthetics in case

spontaneous breathing• 4. Accidental event- CO2 emphysema, Capnothorax CO2 embolism

CARDIOVASCULAR CHANGES AND GIT EFFECTS:

• These changes are characterized by :Decreased cardiac outputElevation of arterial pressure and pulmonary vascular resistanceHR may decrease or increase

• G I T CHANGES:Patient are considered at high risk acid aspiration syndrome due to increased intragrastic pressure

• MESENTERIC CIRCULATION:The visceral vascular bed is the primary site of compression during raised IAP resulting in organ dysfunction sympathetically mediated vasoconstriction and mechanical compression of abdominal organ

HEPATIC AND RENAL COMPLICATIONS:

• HEPATORENAL CIRCULATION: Increase IAP > 20mmhg decreases portal blood flow by 60% resulting liver dysfunction

• RENAL DYSFUNCTION:Urine output. Renal blood flow and GFR decrease to less than 50% of base line value .Urine out put increases significantly after desufflation

EFFECT ON CEREBRAL BLOOD FLOW AND TEMPRATURE:

• CERBRAL BLOOD FLOW :Both ICP and IOP are raised due to vasodialating action of CO2

• HYPOTHERMIA:joule Thompson effect . some aggravating factors are higher flow rate ,prolong duration of surgery, leakage through port ,peritoneal lavage etc .There is 0.30 c fall in core temperature per 50l volume flow of carbondioxide .

CAN LAPAROSCOPY BE PERFORMED IN ALL PATIENT ???????

Careful consideration :• ICP , SOL and CVA • ventriculoperitoneal and juguloperitoneal

shunt .• Hypovolumic patient • Cardiac diseas Patient with renal dysfunction.• H/o of deep vein thrombosis

EFFICACY OF SPINAL ANAESTHESIA:

• Laparoscopic cholecystectomy under spinal anaesthesia: A prospective, randomised study

• Sangeeta Tiwari, Ashutosh Chauhan et al• Author information ► Article notes ►

Copyright and License information ►• EVALUATED SAFETY OF SPINAL ANAESTHESIA IN

Year 2013• RESULTS: Spinal anaesthesia In Laparoscopic

routine anaesthesia choice -feasible and safe

REGIONAL ANAESTHESIA FOR LAPROSCOPIC SURGERY A NARRATIVE REVIEW

• George Vretzakis,&,etaxia Bareka,,et al year 2014, Journal Of Anaesthesia.

Abstract• Laparoscopic-Reduced morbidity,shorter hospital stay cf open surgery.

Laparoscopic - performed increasingly in sick patients, anesthesia unchanged. General anesthesia used- except “too sick” for general anesthesia. Recently-retrospective studies questioned general anesthesia - the best.Later studies suggested that regional anesthesia can reasonable choice - certain settings. This narrative review is an attempt to critically summarize current evidence on regional anesthesia for laparoscopic surgery.

• INCONCLISIVE STUDY:This is retrospective study, large, rigorous, prospective clinical trials comparing regional vs. general anesthesia needs to be done

Thoracic epidural anesthesia for laparoscopic cholecystectomy using either bupivacaine or a mixture of bupivacaine and clonidine: A comparative clinical study-Malti Agrawala, et al Deparment of Anesthesiology and Critical Care, Rohilkhand Medical College and Hospital, Bareilly, Uttar Pradesh, India ,Year 2013

Abstract Introduction: central neuraxial blockade. Achieved a better results.

Patients and Methods: 50 Patients

Results: All the parameters of the patients in group A remained stable but the patients of group B showed an increase in mean arterial pressure (MAP) and HR at 5, 15 and 30 min after PNO and 15 min after exsufflation as compared to Group A. PaCO 2 , SpO 2 and RR values in both the groups were comparable. In group A, two patients complained of shoulder pain while in group B12 patients complained of shoulder pain.Conclusion: Thoracic epidural (Addition of clonidine (2 μg/kg ) to bupivacaine better qualitative conditions.Prevents hemodynamic perturbations produced by pneumoperitoneum Decreases the incidence of shoulder pain. clonidine as an adjuvant in thoracic epidural anesthesia for LC.

BENIFITS OF EPIDURAL:

• Pain management allowing for faster mobility

• Reduced risk of nausea or vomiting• Reduced risk of lung/leg blood clots• Reduced risk of chest infections• Faster return to eating and drinking

ONE CENTURY OF THORACIC SPINAL ANESTHESIA HISTORY

• In 1909, Thomas Jonnesco - Thoracic spinal block for surgeries of the neck, and thorax.

• T1 and T2 vertebrae• ‘ I have a total of 1,015

thoracic spinal analgesia all without death and without any serious complication

ONE CENTURY OF THORACIC BLOCK

NEW ERA STARTED 2006• In 2006, Andre Van

Zundert et al. proposed segmental spinal block, for lap cholecystectomy in a patient with severe obstructive lung disease, using a low thoracic puncture (T10) for CSE block. van Zundert AJ, Stultiens G, Jakimowicz J et al. Segmental spinal patient with severe lung disease. Br J Anaesth, anaesthesia for cholecystectomy in a 2006;96:464-466.

Major Concern…..?

What makes it accepted?!!!! PROs

Neurologists and radiologists perform subarachnoid myelographic injections at mainly cervical (occasionally thoracic) levels.

Robertson HJ, Smith RD. Cervical myelography: survey of modesof practice and major complications. Radiology. 1990;174:79Y83 Yousem D.M. , Gujar S.K. Are C1–2 Punctures for Routine Cervical Myelography below the Standard of Care? A JNR 2009;30:1360-1363

What makes it accepted?!!!! PROs…Anatomical Explanation

Imbelloni L E et al. Magnetic resonance imaging of the spinal column Br. J. Anaesth. 2008;101:433-434Imbelloni L E , Gouveia Low Incidence of Neurologic Complications during Thoracic Epidurals: Anatomic Explanation AJNR Am J Neuroradiol.2010; 31: E84

How To Perform A Thoracic

Spinal Techniquevan Zundert AA, Stultiens G, Jakimowicz JJ et al. Laparoscopic cholecystectomy under segmental thoracic spinal anaesthesia: a feasibility study. Br J Anaesth 2007.Lee RA,Van Zundert AAJ,Visser WA et al.Thoracic combined spinal epidural anesthesia. SAJAA 2008; 14(1): 63-69

Technique

Patients are placed in the left lateral/sitting position

van Zundert AA, Stultiens G, Jakimowicz JJ et al. Laparoscopic cholecystectomy under segmental thoracic spinal anaesthesia: a feasibility study. Br J Anaesth 2007.Lee RA,Van Zundert AAJ,Visser WA et al.Thoracic combined spinal epidural anesthesia. SAJAA 2008; 14(1): 63-69

What makes this technique segmental DR Den Larie

RecommendationsPatient safety takes precedence over unnecessary risks to be taken for the success of the procedure.It is not a method that could be easily and safely applied by the majority of anesthetistsThis technique is reserved for experienced clinicians working in defined and approved evaluation programes, and that it must not yet be used in routine clinical practice

CAN ANY BODY HAVE EPIDURAL:

Following May BE Avoided:• Taking blood thinning drugs• History of blood clots• Allergy to anaesthetics• Severe deformity or arthritis of the spine• Infection on your back

COMPLICATIONS OF EDIDURAL:• Failure of the epidural• Feeling nauseous or vomiting• Low blood pressure• Headaches• Respiratory depression• Itching• Difficultly passing urine• Backache• Leg weakness

• Rare complications may include:

• Seizures• Infection around the spine• Cardiovascular problems• Blood clots• Damage to nerves• Paralysis or death

HOW DOES EPIDURAL WORKS:

• The anaesthetic numbs the nerves to give you pain relief in various areas of your body.

• Epidurals can be used awake, or together with sedation or general anaesthesia.

• After operation to give effective pain relief. Epidural -maintained by Extra doses when needed or continuous low dose

DOES PATIENT FEEL ANY THING:

• The local anaesthetic might sting briefly. When the catheter is inserted. Occasionally patients feel an sensation Like electric shock or pain. Tell the anaesthetist immediately if this happens.

• Epidural begins to work the lower part of your body will feel very heavy. You not able to move your legs.

• Epidurals used during and after procedure for pain management. The epidural catheter removed once pain is managed. The numbness and decrease over the day following procedure. Safety - ask for help out of bed or moving around

HOW EPIDURAL IS ADMINISTERED:

• How is epidural anaesthesia administered?• You will meet with the anaesthetist prior to your procedure and he/she

will be with you throughout your time in theatre. Staff will assist you getting into a curled up position on a bed. You might be asked to bend forward and hug a pillow or to lie on your side curled up with your knees drawn toward your chest. We understand this can be an anxious time so staff will be with you to reassure and support you during the injection.

• Local anaesthetic will be injected into a small area of the skin on your back. The anaesthetist will use a needle to insert a thin plastic tube (epidural catheter) into your epidural space. The needle is then removed. A small amount of anaesthetic will be inserted through the catheter to check it is in the right position. Once this check is completed the anaesthetist will inject more of the drug until the epidural is working properly

The Effectiveness of Preemptive Thoracic Epidural Analgesia in Thoracic SurgeryEngin Erturk,1 Ferdane

Aydogdu Kaya,1 et al,2013,TURKEY

• Patients 65 In conclusion we consider that preemptive TEA -Better analgesia after thoracic surgery. However, further studies - more patients are needed to demonstrate benefits of preemptive epidural analgesia providing better analgesia with less side effects and positive outcomes from stress response.

Laparoscopic cholecystectomy under epidural anesthesia: a clinical feasibility study

Ji Hyun Lee,1 Jin Huh,3 et al ,Korean Journal,2010

• Patients-12• Background Laparoscopic cholecystectomy owing to the advancement of surgical and

anesthetic techniques, many laparoscopic cholecystectomies have been successfully performed under the spinal anesthetic technique. We hoped to determine the feasibility of segmental epidural anesthesia for LC.

• Methods :Done with 12 patients LC was performed successfully under epidural block, with the exception of 1

patient who required a conversion to general anesthesia owing to severe referred pain. There were no special postoperative complications, with the exception of one case of urinary retention.

• Conclusions Epidural anesthesia might be applicable for LC. However, the incidence of

intraoperative referred shoulder pain is high, and so careful patient recruitment and management of shoulder pain should be considered.

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