Measuring abdominal compliance to provide optimal surgical conditions.

53 Pages·2013·11.17 MB·English

by  Jan Paul Mulier

1
1150 1850 1947 1977 2013
Measuring abdominal compliance to provide
optimal surgical conditions.

Jan Paul Mulier MD PhD
Anaesthesiologist

Sint-Jan Brugge, Belgium

JPMulier 2012
Can we do something to improve the 22
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 and why should I always have to
ask that?
Intraabdominal pressure ?
Intraabdominal volume? —  Anesthesiologist: The patient has only one
TOF response in the AP. Last time this was
Workspace?
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 yoLujur bslujapnear,v i1s8o Ar!p ril 2012
JPMulier 2012
Insufficient NMB during lap: 3
how do surgeons recognize it?
—  At the first insufflation with the verres needle
—  High abd pressure to start > 8 mmHg.
—  No flow is going inside.
—  Multiple attempts to reposition.
—  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.
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4
Various Depths of NM Blockade
Posttetanic Twitch Twitch
count count response
Level of block Intense block Deep block Moderate block Superficial block
Response to TOF TOF count 0 TOF count 0 TOF count 1-3 TOF count 4
Response to PTC PTC 0 PTC ≥1 PTC ≥20 T4 / T1 %
—  Intense blockade: no response to either TOF or PTC stimulation
—  Deep blockade: response to PTC but not to TOF stimulation
—  Moderate blockade: reappearance of response to TOF stimulation
—  Superficial blockade: T4 response divided by T1 response
PTC, posttetanic count; TOF, train-of-four.
JPMulier 2012
Fuchs-Buder T, et al. Acta Anaesthesiol Scand. 2007;51:789-808.
55
Yes we can
—  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 the IAP is low.
—  Anesthesiologist: the patient is now on
a deep neuromuscular block
—  Surgeon: how manu PTCs has the
patient in the adductor pollicis
Posttetanic
count
—  Anesthesiologist: only 3 PTCs, I will
keep him on a deep NMB until the end
—  Surgeon: thanks, then we will end in
time and we can have a drink together
Deep block
Ljubljana, 18 April 2012
TOF count 0 JPMulier 2012
PTC ≥1
6
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?
Variability of inflated abdominal volume
10
at 15 mmHg pneumoperitoneum
8 without NMB

r
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V

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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
7
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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Pressure volume loops
8
or
Simplified 3 points measurement
or
Look to max vol at 15
PV0 : 7

E: 1 mmHg/L
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9
CT scan
• Mulier J.P., Coenegrachts CT analysis of the elastic deformation and elongation of the abdominal
wall during colon inflation for virtual coloscopy JPMulier 2012
Eur J Anesthesia 2008 Suppl
10
Compliance (C) and Elastance (E)
C=change in V/change in P (C= 1/E)

Higher insufflation pressures needed
PV0 = 5
E = 4 mmHg/l
Insufficient intra
abdominal volume
J Mulier, B Dillemans, M Crombach, C Missant, A Sels
On the abdominal pressure volume relationship.
JPMulier 2012
The Internet Journal of Anesthesiology. 2009; 21: 1.