Measuring abdominal compliance to provide optimal surgical conditions.

59 Pages·2013·12.57 MB·English

by  Jan Mulier

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1150 1850 1947 1977 2013
Measuring abdominal compliance to provide
optimal surgical conditions.

Jan Paul Mulier MD PhD
Anaesthesiologist

Sint-Jan Brugge, Belgium

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1926: Deep general anesthesia
became possible
“a new future of anaesthesia?”
  Ann meeting BMA,Nottingham:
  Samuel Johnston, President of the section of Anaesthetics:
  “For once there could be an association of surgery and
anaesthesia without the question of sufficient relaxation
arising”
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1942: Introduction of curare a
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solution for surgery?
The use of curare in 25 patients by Harold Griffith in 1942 changed
anesthetic practice throughout the world and heralded the start of the
modern era of anesthesiology.
The introduction of curare allowed adequate muscle relaxation at a
lighter and therefore better-tolerated degree of general anesthesia.
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Anesthesiology 1942;3:418-20
‘2009’ Sugammadex allows very fast 4
decurarisation in every patient from every
depth of NMB
  Sugammadex is a safe drug with no side effects
  Is Sufficient relaxation now possible for the surgeon ?
  However not used by every anesthesiologists. Why?
  Price concern for anesthesia budget
  Pride to work without decurarisation, even without NMB!
  “Just enough to do the job”
  Changing your behaviour is the most difficult task and
afterwards an explanation is invented.
  Who really needs sufficient muscle relaxation?
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Gynecologic laparoscopy possible without NMB?
  Gynecologic laparoscopy with or without curare?
  Chassard D Ann Fr Anesth Reanim 1996; 15: 1013
  A comparison of the effect of two anaesthetic techniques on surgical conditions
during gynaecological laparoscopy
  Williams MT. Anaesthesia. 2003; 58: 574
  No supplemental muscle relaxants are required during propofol and remifentanil total
intravenous anesthesia for laparoscopic pelvic surgery.
  Peak CM J laparoendosc Adv Surg Tech 2009; 19: 33
  Effect on workspace was never measured Surgeon was asked if he
could work.
  But without curare higher PV0 and trocar placement more
difficult.
  Non obese patients, working in pelvic region at relative high IAP.
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Do you recognise this 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
Intraabdominal pressure ?
TOF response in the AP. Last time this was
Intraabdominal volume?
enough. Why not today with you?
Workspace?
  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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Abdominal inflation volume 7
Why this difference: Patient variability
  Inflated volume at 15 mmHg without NMB: from 0,5 L to 10 L.
  Who needs NMB ?
  Will the surgeon be comfortable without NMB ?
Variability of inflated abdominal volume
10
at 15 mmHg pneumoperitoneum
8 without NMB

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0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 1p6a tie17n t n18r 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33
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Example: 1,2 L versus 7,2 L
Maximal NMB helps but is not
sufficient alone

NMB needed? Depends on the IAP
used?
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But what needs the surgeon?
Surgeon needs high IAP to
put trocar at the start

Surgeon needs space to

work during laparoscopy
Low pressure vs high
Low volume vs high
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Optimal surgical work conditions
1.  Sufficient lap workspace > 2 L; ideal 4 L
1.  How to measure and predict this?
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