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How to make a friend of your laparoscopic surgeon?
JPMulier 2012
1150 1850 1947 1977 2013
Jan Paul Mulier MD PhD Anaesthesiologist
Sint-Jan Brugge, Belgium
Can we do something to improve the situation?
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!
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Intraabdominal pressure ? Intraabdominal volume?
Workspace?
CAPE 2013
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Insufficient lap workspace: how surgeons recognize it?
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!
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CAPE 2013
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 JPMulier 2012
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Prediction of insufficient workspace:
JPMulier 2012
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Example of insufficient workspace
PV loops with fit
0
10
20
30
40
-0,5 0 0,5 1 1,5 2 2,5
IAV liter
IAP
mm
Hg
IAP
1. No muscle relaxation
2. Active contraction against ventilator
3. Full muscle relaxation
051015202530354045
0 500 1000 1500 2000 2500 3000
IAP
mm
hg
-0,5
0
0,5
1
1,5
2
2,5
IAV
liter
IAPIAV
no relaxation valsalva contract relaxation
1 2 3
2 1 3
Example: 1,2 L versus 7,2 L
JPMulier 2012
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Maximal NMB helps but is not sufficient alone NMB needed? Depends on the IAP used?
JPMulier 2012
7 Why this difference: Patient variability Inflated volume at 15 mmHg without NMB varies from 0,5 L to
10 L.
Who needs NMB?
Will the surgeon be comfortable?
0
2
4
6
8
10
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33
infl
ated
Vol
ume
liter
patient nr
Variability of inflated abdominal volume at 15 mmHg pneumoperitoneum
without NMB
Compliance (C) and Elastance (E) C=change in V/change in P (C= 1/E)
PV0 = 5
E = 4 mmHg/l
Higher insufflation pressures needed
J Mulier, B Dillemans, M Crombach, C Missant, A Sels On the abdominal pressure volume relationship. The Internet Journal of Anesthesiology. 2009; 21: 1.
Insufficient intra abdominal volume
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JPMulier 2012
Three point calculation before after leg flexion
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JPMulier 2012
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Effect of leg flexion on APVR
PV0 4,320 = 4,76571
E 3,459 > 2,66067
5,037 = 4,91096
3,368 > 2,577
• PV0 no change • E decreases
Mulier JP Obes Surg 2009 JPMulier 2012
Three point calculation before after deep NMB
JPMulier 2012
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Use of NMBA is Associated With Decreased Frequency of Poor Surgical View Conditions1,a
1. King M. Anesthesiology. 2000;93:1392–1397.
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.
Placebo n=61
NMBA n=59
P<0.001 placebo vs NMBA
% P
atie
nts
wit
h po
or
surg
ical
vie
w c
ondi
tion
s
NMBA=neuromuscular blocking agent. JPMulier 2012
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Difference Between Diaphragm and Adductor Pollicis
• 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
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JPMulier 2012
Time difference when bolus NMB given between abdomen – adductor pollices
Kirov K et al. Ann Fr Anesth Reanim. 2000;19:734–738.
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
JPMulier 2012
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Solution to Both Problems: Continuous Infusion to a Deep Block
Deep NMB could remain in place for duration of procedure
followed by rapid predictable reversal
JPMulier 2012
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JPMulier 2012
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BMI effect on abdominal P/V relation
-4
-2
0
2
4
6
8
10
0 10 20 30 40 50 60
PV
0 in
mm
Hg
BMI
Effect of BMI on PV0
0
0.002
0.004
0.006
0.008
0.01
0.012
0 10 20 30 40 50 60
E in
mm
Hg/
l
BMI
Effect of BMI on E
J Mulier ISPUB 2009 Pressure volume relation is linear
PV0 and E are patient determined
J Mulier IFSO 2007
JPMulier 2012
17 Two types of android obesity
Intra visceral adiposity Extra visceral adiposity
Subcutaneus fat is scant and Subcutaneus fat is thick and
intra abdominal fat is thick and intra abdominal fat is scant.
Subcutaneus Fat Visceral fat -‐50
0
50
0 0, 5 1 1, 5 2 2, 5 3 3, 5 40
0, 5
1
1, 5
0 0, 2 0, 4 0, 6 0, 8 1 1, 2
abdominal pressure in android shape with intra visceral fat
0
5
10
15
20
25
0 1 2 3 4IAV in liter
IAP
in m
mH
g
Thicness of external fat
JPMulier 2012
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Other techniques used to improve surgical wokspace and access:
1. 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.
JPMulier 2012
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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.
What would you do? High PV0 and normal compliance
0
5
10
15
20
25
0 1 2 3 4 5 6
IAP m
mHg
IAV liters
APVR of patient 3
pat 3
0
5
10
15
20
25
0 1 2 3 4 5 6
IAP m
mHg
IAV liters
APVR of patient 3
pat 3
pat 3 deep NMB
Patient 3 PV0 = 0 E = 0.2 L/mmHg
To get a volume of 4 liters we need an IAP of 12 + 4/0,4 = 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.
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
0
5
10
15
20
25
0 1 2 3 4 5 6
IAP m
mHg
IAV liters
APVR of pt 4
pat 4
0
5
10
15
20
25
30
35
40
0 1 2 3 4 5 6
IAP m
mHg
IAV liters
APVR of pt4
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 13 + 4/0,15 = 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.
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
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Yes we can do something move the blood brain barrier down
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.
Surgeon: thanks, then we will end in time and we can have a drink together
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CAPE 2013
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Measure to know who needs deep NMB.
CAPE 2013
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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.’
02/06/13 ESA 2013 O5RC1 J P Mulier
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December 14th 2013Crown Plaza, Burg 10Bruges, Belgium.
4thESPCOP
meeting
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
and the practical consequences for us in our daily clinical work.
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