A 41-year-old female presented with right upper quadrant abdominal pain and was diagnosed with symptomatic gallstones and acute cholecystitis. She underwent a laparoscopic cholecystectomy under general anesthesia. General anesthesia was induced and tracheal intubation was performed. Pneumoperitoneum was created and maintained at 12 mmHg during the laparoscopic procedure. The surgery was completed without complications and the patient was extubated and transferred to the recovery unit in a stable condition.
DIABETES AND ITS ANAESTHETIC IMPLICATIONSSelva Kumar
This presentation deals with diabetes mellitus and its anaesthetic implications. All about preoperative investigations and intra-operative management are discussed.
DIABETES AND ITS ANAESTHETIC IMPLICATIONSSelva Kumar
This presentation deals with diabetes mellitus and its anaesthetic implications. All about preoperative investigations and intra-operative management are discussed.
Anesthetic consideration in smokers,alcoholics and addictsAftab Hussain
Anaesthetic consideration in smokers alcoholic and drug addicts. As an anaesthesiologist we must be aware with the problems associated with their management and interaction with anaesthetics.
Anesthetic consideration in smokers,alcoholics and addictsAftab Hussain
Anaesthetic consideration in smokers alcoholic and drug addicts. As an anaesthesiologist we must be aware with the problems associated with their management and interaction with anaesthetics.
World Laparoscopy Hospital provides learning by doing. It provides real-world laparoscopic surgery experience by allowing the trainee to get hands-on directly with whatever surgeons are learning and developing a sense of empowerment. After taking this laparoscopic training course, surgeons and gynecologists can perform laparoscopic surgery them self on their patients with confidence.
The anesthetic problems during minimal access surgery
are related to the cardiopulmonary effects of pneumoperitoneum, carbon dioxide (CO2) absorption, extraperitoneal
gas insufflation, venous embolism, and inadvertent injuries
to intraabdominal organs. Optimal anesthetic care of
patients undergoing laparoscopic surgery is very much
important. Good anesthetic techniques facilitate riskfree surgery and allow early detection and reduction of
complications.
In young patients, fit for diagnostic laparoscopy, general
anesthesia is the preferred method and does not impose
any increased risk. Adequate anesthesia and analgesia
are essential and endotracheal intubation and controlled
ventilation should be considered. The pneumoperitoneum
can be created safely under local anesthesia provided that
the patient is adequately sedated throughout the procedure.
For successful laparoscopy under local anesthesia, intravenous (IV) medication for sedation should be given
The anesthetic problems during minimal access surgery are related to the cardiopulmonary effects of pneumoperitoneum, carbon dioxide (CO2) absorption, extraperitoneal
gas insufflation, venous embolism, and inadvertent injuries to intraabdominal organs.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
263778731218 Abortion Clinic /Pills In Harare ,ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group of receptionists, nurses, and physicians have worked together as a teamof receptionists, nurses, and physicians have worked together as a team wwww.lisywomensclinic.co.za/
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
2. 41-year-old female, married, residing at wadala (E),
Mumbai, admitted with a complaint of significant right
upper quadrant abdominal pain for 3 days, constant and
radiating to the tip of the right scapula. The pain was
associated with nausea and few bouts of vomiting.
There was no history of jaundice and no history of fever
at the time of admission.
On examination upon presentation, the patient was
conscious, alert, and oriented. She was in pain and
mildly dehydrated. She had normal vitals and she was
not jaundiced.
Laboratory results are as follows: white cell count,
13700 cells/mL, normal (total bilirubin, direct bilirubin,
serum amylase, urea and electrolytes, and coagulation
profile).
3. Pregnancy test was negative.
Chest and abdominal X-rays were within normal
limits.Ultrasound was done which showed impacted
stone and the neck of the gallbladder, distended
gallbladder with wall edema and double wall sign.
After confirming the case as being symptomatic
gallstones with acute cholecystitis, laparoscopic
cholecystectomy was planned.
After obtaining written informed consent for anesthesia
and surgery, in OT,the patient was placed in supine
position.
. General anesthesia was induced with midazolam 1mg
i.v., and fentanyl 100 mcgs i.v., and propofol 80mg i.v.,
4. Rocuronium was administered to facilitate tracheal
intubation. After tracheal intubation with 7mm cuffed
ET Tube, anesthesia was maintained with sevoflurane
and fentanyl.
Conventional four-port laparoscopic cholecystectomy
was carried out. The pneumoperitoneum was
maintained at 12 mmHg.
The surgery was uneventful and the patient remained
haemodynamically stable throughout the procedure.
After a smooth emergence from anaesthesia and
reversal of neuromuscular block, her trachea was
extubated without any adverse events. The patient was
then transferred to the post-anaesthesia recovery unit
5. Overview
Introduction & History.
Definition, IAP.
Risks & Benefits.
Alteration in physiology (System wise).
Associated complications & treatment.
Effect of position.
Conduct of anaesthesia.
Conclusion.
6. Introduction
1985: first laparoscopic cholecystectomy performed in
Germany
Richard Zollikofer of Switzerland promoted the use of
Carbon dioxide for insufflating peritoneum
Defination - Laparoscopy is a “minimally invasive”
procedure allowing endoscopic access to the peritoneal
cavity after insufflation of a gas to create space
between the anterior abdominal wall and the viscera.
7. Advantages of Laparoscopy
Day care surgery
Shorter hospital stay
Improved cosmesis
Less post-op ileus
Faster recovery
Rapid return to normal activities
Minimal pain
Small scar
Better preservation of resp fn
8. Disdvantages……
More expensive
Difficult in complicated cases
Eg. Obesity, pregnancy, previous abdominal surgery
Potential for major complications like damage to
viscera and vascular injury
Pneumoperitonium leading to VQ mismatch
LL pain, rhabdomyolysis and potentially myoglobin
associated acute renal failure
10. Laparoscopy – Anesthesia
concerns
CO2 pneumo peritoneum
Due to patient positioning
Cardiovascular effects
Respiratory effects
Gastro intestinal effects
Unsuspected visceral injuries
Difficulty in estimating blood loss
Darkness in the OR
11. Intra-abdominal
pressure(IAP)
IAP is the steady pressure within the closed
abdominal cavity.
normal values of IAP are 0-5 mmHg.
values more than 12-14 mmHg compromises venous
return.
Initial flow : 4-6 L/min.
Maintenance : 200-400 ml/min.
12. Insufflator Gas used
N2O /CO2 /Argon /He/ Air
Preferred gas : CO2
Working pressure : 12 to 14 mm Hg
Slow inflation of 1 liter / minute
(Air & O2 –risk of embolism high)
N2O –bowel distension,risk of explosion, PONV.
He & Argon not available here- embolism)
13. CO2 as Insufflator Gas
More soluble in blood than air
Carriage is high due to bicarbonate buffering
and combination with Hb
Rapidly eliminated by lungs
Inert & not irritant to tissues
14. Gasless laparoscopy….
Peritoneal cavity is expanded using abdominal wall
lift obtained with a fan retractor.
Gasless laparoscopy compromises surgical exposure
and increases technical difficulty.
Appealing for patients with severe cardiac or
pulmonary disease.
15. What happens on creating a
pneumoperitoneum?
As the volume of the abdomen increases, abdominal wall
compliance decreases and intra-abdominal pressure (IAP) climbs.
When the IAP exceeds physiological thresholds, blood flow in
individual organ systems become compromised, potentially
increasing patient’s morbidity and mortality.
16. What are the hemodynamic effects of
pnuemoperitoneum in CVS?
17. Physiological effects
Cardiovascular
There is biphasic response on CO
IAP <10mmHg, milking effect on veins increasing CO
If IAP >15mmHg, 10%-30% reduction in CO
increase in systemic vascular resistance, mean
arterial pressure, and cardiac filling pressures
more severe in patients with preexisting
cardiac disease
significant changes occur at pressures greater
than 12 - 15 mmHg
(ASA class III Patients or IV) who are volume
depleted experience the most severe
hemodynamic changes.
18. Physiological Effects
Increased noradrenalin levels leads to increased
SVR
increased plasma renin activity (PRA) due to
increased intra-abdominal pressure (IAP) and the
local compression of renal vessels
Hypertension, tachycardia leading to increased
myocardial oxygen demand
Hypercarbia and acidosis
19. Reasons for arrythmias during
laparoscopy….
1. Reflex increases of vagal tone may result from sudden
stretching of the peritoneum.
2. Hypercarbia & hypoxia.
3. Gas embolism.
4. Lighter planes of anaesthesia.
5. Volatile anaesthetics
Treatment consists of interruption of insufflation, atropine
administration, inj. Lignocaine, Amiodarone and deepening of
anesthesia after recovery of the heart rate.
20. Management of CVS
changes-
Intermittent pneumatic compression to legs will improve
venous return
Preoperative preload augmentation offsets the hemodynamic
effect of pneumoperitoneum.
Intravenous nitroglycerin, nicardipine, or dobutamine has
been used to manage the hemodynamic changes induced by
increased IAP.
Use of alpha 2 agonist such as clonidine or dexmedetomidine
& or beta blocker reduces haemodynamic changes
21. Pulmonary changes
Exaggerated in obese patients, ASA classII and III patients
& in those with respiratory dysfunction
Intra-abdominal distension leads to a decrease in
pulmonary dynamic compliance
1. increased IAP displaces the diaphragm upward
2. functional residual capacity and total lung
compliance decreases by 30 to 40%
3. Early closure of smaller airways, basal atelectasis
4. increased peak airway pressures
5. increase in minute ventilation required to maintain
normocarbia
6. Increase in intra pulmonary shunting
7. Approximately 15 min after abdominal deflation,
respiratory compliance and resistance return to pre-
insufflation level.
22. Effect of pnuemoperitoneum on
PaCO2?
CO2 is absorbed from the peritoneal cavity and
carried by blood through the systemic and portal
veins and excreted via the lungs.
Pneumoperitoneum increases pulmonary excretion of
CO2 (VCO2) and PaCO2.
High increase in VCO2 and PaCO2 does not happen
because of impaired peritoneal perfusion due to
haemodynamic changes and enormous buffering
capacity of the blood.
23. PaCO2
under general anesthesia, PaCO2 progressively
increases and reaches a plateau 15 to 30 min after
beginning of CO2 insufflation.
the main mechanism of the increased PaCO2 during
CO2 pneumoperitoneum is absorption of CO2 rather
than the mechanical ventilatory repercussions of
increased IAP.
Correction of increased PaCO2 can be achieved by a
10% to 25% increase in alveolar ventilation.
24. What is the role of Capnography
during laparoscopy
It serves as a non-invasive monitor of PaCO2 during
CO2 insufflation.
helps in detection of accidental intravascular
insufflation of CO2.
EtCO2 increases in Endo-Bron.Intubation, Sub.
Cut.emphysema & capnothorax and decreases in
Pneumothorax & CO2 embolism.
25. Capnography during
laparoscopy…
Mean gradients (Δa-EtCO2) do not change significantly
during peritoneal insufflation of CO2.
lack of correlation between PaCO2 and EtCO2 is seen
particularly in those with impaired CO2 excretion
capacity, and cardiopulmonary disturbances.
Hypercapnia can develop, even in the absence of
abnormal EtCO2.
Postoperative intra-abdominal CO2 retention can
result in increased respiratory rate and EtCO2 of
patients breathing spontaneously.
26. Physiological effects of
carbon- dioxide cont’d…..
10-15 minutes after CO2 insufflation due to reflex
vasodilatation, an increase in ICP is seen.
PaCO2 level has the regulatory effect on ventilation via
central & peripheral chemoreceptors.
CO2, which easily crosses the blood-brain barrier, indirectly
controls inspiratory centre by formation of carbonic acid,
which dissociates to produce HCO3
- and H+ & increase in the
rate of respiration.
The maximal stimulation is attained at a PaCO2 level of about
100 mmHg. Any further increase results in respiratory
depression.
27. Physiological effects of
carbon- dioxide cont’d…..
The cardiovascular effects of hypercarbia are the
result of a balance between the direct
cardiodepressant effect of CO2 and increased activity
of the sympathetic nervous system.
Activation of the sympathetic nervous system by CO2
in healthy individuals overcompensates for direct
cardiodepression.
28. Gastro intestinal system
Risk factor for Regurgitation
Increased intra-abdominal pressure
Decreased lower esophageal sphincter tone (if barrier
pressure is increased>30cm of H2O)
Head down position
NG tube mandatory
29. Gastro intestinal system..
Mesentric circulation:
Reduced bowel circulation resulting
in decreased gastric intra mucosal
pH
Due to IAP, collapse of capillaries
and small veins,
Reverse Trendelenburg position,
Release of vasopressin
all lead to decreased mesenteric circulation
30. Gastro intestinal system...
Porto Hepatic circulation:
Rise in IAP result in decreased total hepatic blood flow due
to splanchnic compression
Hormonal release (catecholamine, Vasopressin &
Angiotensin lead on to overall reduction in splanchnic
blood flow except for Adrenal glands)
Reverse Trendelenburg position,
Release of vasopressin
all lead to decreased mesenteric circulation
31. Renal function
Increased IAP
decreased RBF
increased sympathetic activity
elevated plasma Renin activity
fall in filtration pressure
fall in urine output
32. Central Nervous System
Increased IAP Increased lumbar spinal pressure
Decreased drainage from lumbar plexus Increased
ICP
Hypercapnia, high systemic vascular resistance and
head low position combine to elevate intracranial
pressure.
The induction of pneumoperitoneum itself increases
middle cerebral artery blood flow
33. Coagulation System
Increased IAP may lead to increased venous stasis
causing deep vein thrombosis especially in prolonged
surgery
deep vein thrombosis prophylaxis
should be done in such patients.
34. Temperature Variation
Continuous flow of dry gases into peritoneal cavity
under pressure can lead to fall in body temperature.
(sudden expansion of gas produces hypothermia due to
Joule Thompson effect)
0.30 C fall in core temperature/50 Lit flow of CO2
35. Neuro humoral response
Activation of Hypo thalamo pituitary Adreno cortical
Axis
Rise in ACTH, Cortisol and Glucogon
Altered glucose metabolism
Laparoscpic surgery is as stressful as
conventional surgery
36. Complications of lap
surgeries
Due to trochar injury
Positioning and compression effect
CVS and RS complications
Thermal injuries
Gas embolism
37. Complications of gas
insufflation
Subcutaneous emphysema
occur if the tip of the Veress needle does not
penetrate the peritoneal cavity prior to
insufflation of gas.
Occur in inguinal hernia repair, renal surgery
During fundoplication for hiatus hernia repair
Extraperitoneal insufflation, which is associated
with higher levels of CO2 absorption than
intraperitoneal insufflation, is reflected by a
sudden rise in the EtCO2, excessive changes in
airway pressure and respiratory acidosis
CO2 subcutaneous emphysema readily
resolves after insufflation has ceased
38. Respiratory Complications:
2) Pneumothorax, Pneumomediastinum,
Pneumopericardium
peritoneal cavity ---potential channels--- pleural and
pericardial sacs.
Defects in the diaphragm or weak points in the aortic
and esophageal hiatus allow gas passage into the
thorax.
pleural tears occurs during laparoscopic surgical
procedures at the level of the gastroesophageal
junction.
For diffusible gas such as CO2 without associated
pulmonary trauma, spontaneous resolution of the
pneumothorax occurs within 30 to 60 minutes.
39. Management of
Pneumothorax
Stop N2O
Adjust ventilator settings to correct
hypoxemia
If due to pleuro peritoneal channel route
Apply PEEP
Reduce intra-abdominal pressure
Communicate with surgeon
Avoid thoracocentesis unless necessary
Avoid PEEP if there is rupture of
emphysematous bulla and
thoracocentesis is mandatory
40. Respiratory Complications:
3)Endobronchial Intubation
cephalad movement of the carina & diaphragm during
pneumoperitoneum, leads to endobronchial
intubation.
Oxygen saturation decreases as measured by pulse
oximetry (SpO2) associated with an increase in
plateau airway pressure & increase in EtCO2 .
41. Respiratory Complications:
4) Gas Embolism
most feared and dangerous complication of
laparoscopy.
Early events, occurring with 0.5 mL/kg of air or less,
include changes in Doppler sounds and increased
mean pulmonary artery pressure.
lethal dose of embolized CO2 is approximately five
times greater than that of air.
42. Diagnosis of Gas-embolism
Detection of gas in right side of Heart –foamy
blood aspirated in the central venous catheter
Difference between PaCO2 ETCO2 increases.
Recognition of physiological changes secondary to
emboli:
Tachycardia
Cardiac arrhythmia
Hypotension
CVP rise
Mill-wheel murmur
Cyanosis
Right heart strain pattern in ECG
Pulmonary edema
Doppler & TEE ---- very sensitive (0.5ml/kg)
43. Gas Embolism
Suspicion of Gas Embolism
Blood on aspiration from Vere’s needle
Pulsation of flow meter pressure gauge
Disappearance of abdominal distention
despite sufficient volume of gas
44. Treatment of Gas Embolism
Immediate cessation of insufflation
Release of pneumo-peritoneum
Patient in head down and left lateral
decubitus (Durant’s) position
Cessation of N2O
Give 100% oxygen
CVP insertion and aspiration of gas
CPR help to fragment CO2 emboli
into small bubbles
45. How Durant position
helps?
Head-down position keeps a left-ventricular air bubble away from
the coronary artery ostia (which are near the aortic valve) so that
air bubbles do not enter and occlude the cornonary arteries.
Left lateral decubitus positioning helps to trap air in the non-
dependent segment of the right ventricle, preventing it entering
the pulmonary artery & also prevents the air from passing through a
patent foramen ovale.
46. Treatment of gas embolism
cont’d…
A central venous or pulmonary artery catheter may
be introduced for aspiration of the gas.
External cardiac massage may be helpful in
fragmenting CO2 emboli into small bubbles.
Cardiopulmonary bypass of blood has been used
successfully to treat massive CO2 embolism.
Hyperbaric oxygen treatment should be strongly
considered if cerebral gas embolism is suspected.
47. What are the effects of pneumoperitoneum
on Renal physiology?
An IAP of 20 mm Hg will reduce GFR by 25%.
Mechanism for this is postulated to be an impaired renal perfusion
secondary to the combined effect of-
reduced renal afferent flow due to impaired cardiac output and
reduced efferent flow due to raised renal venous pressure.
Diminished RBF is a potent trigger for renal angiotensin aldosterone
system.
48. Effect of pneumoperitoneum on
splanchnic physiology
Initially with an IAP <10 mmHg venous return from splanchnic vessels
increase leading to a transient increase in Cardiac output.
Persistent IAPs over 20 mm Hg will cause a reduction in mesenteric and
gastrointestinal mucosal blood flow by up to 40% with progressive tissue
acidosis.
49. the problems with positioning
during laparoscopy :
Extreme positions place the patient at risk of movement
on the table.
patient should be securely positioned with vulnerable
pressure points and eyes being protected throughout
the procedure.
No significant changes in shunt fraction or dead space
ventilation occurs even in a 10 0 - 20 0 head up or
head down position.
51. Problems due to positioning
cont’d….
Nerve compression due to overextension of the arm must be
avoided.
Shoulder braces should be used with great caution and must not
impinge the brachial plexus.
52. Anaesthetic Plan
Pre-operative assessment
The cardiac and pulmonary status of all patients should
be carefully assessed
Pre-medication
Anxiolytics
antiemetic
H2 receptor blockers
Gastro-kinetic drugs
Preemptive analgesia with NSAIDs
Atropine to prevent vagally mediated bradyarrhythmias
54. Anaesthetic techniques
General anaesthesia
The most common technique used for laparoscopic
surgeries is General anaesthesia
Preloading with crystalloid solution is
recommended
Preoxygenation
During induction of Anaesthesia, avoid stomach
inflation
tracheal intubation – mandatory
PLMA should only be used by experienced LMA
users
NG tube placement for Stomach decompression
Catheterisation to empty the urinary bladder
55. G.A. for laproscopic surgery
bag and mask ventilation before intubation should be minimized
to avoid gastric distension.
insertion of a nasogastric tube may be required to deflate the
stomach-improve surgical view, avoid gastric injury on trochar
insertion.
Maintaining with agents like, Isoflurane, Desflurane & Sevoflurane
blunt the haemodynamic response to pneumoperitoneum.
Nitrous oxide causing nausea & vomiting is controversial. But it may
distend the bowel, in patients with intestinal obstruction.
56. Muscle relaxants
Prevents high intra-abdominal and intra-thoracic
pressures due to pneumoperitoneum..
Muscle paralysis reduces the IAP needed for the same
degree of abdominal distention.
57. About PEEP…
Various studies support that a PEEP of 5 cm H2O should
be considered essential during laparoscopic surgeries to
decrease intraoperative atelectasis.
Addition of titrated levels of PEEP can be used to
minimize alveolar de-recruitment.
But must be used cautiously as increasing PEEP may
further compromise cardiac output.
58. COPD and LAP surgery
Helium for pneumo peritonium
Minimal tilt
Procedure time should be minimized to less than 2hrs
PFT,CXR,ABG, SpO2 in addition to history and physical
examination
Cessation of smoking, adequate bronchodilators,
steroids and chest physiotherapy with incentive
spirometry help to reduce post op pul c/o
59. Laparoscopic surgery in
obese patients
Detrimental effect in respiratory mechanics is due to
supine position and increased weight
Carbon dioxide production and oxygen consumption are
increased.
Reduced chest wall compliance & decreased lung
compliance.
FRC will be reduced 25 per cent in the supine position,
with a further reduction of 20 per cent with
Anaesthesia.
airway closure and hypoxemia,
Increase in intrapulmonary shunting.
Alterations to gastric function and drug distribution. In
obese patients, the umbilicus is located 3-6cm caudal to
the aortic bifurcation, making trocar placement more
difficult..
60. Laparoscopic surgery in
obese patients
complications may be reduced by filling the
peritoneal cavity with carbon dioxide (CO2) to a
predetermined pressure level rather than to a
preset volume
Tilt Test:
Placing the patient in steep Trendelenburg for two
to five minutes following intubation and
positioning, observing the patient’s cardiac and
respiratory indices. Patients who remain
Normotensive and maintain peak airway pressures
at < 30-40mmHg during the Tilt Test
before and after insufflation , the surgery is
relatively straightforward, producing excellent
results.
61. Lap cholecystectomy in
pregnancy…
Increased risk of acid aspiration
Increased risk of abortion/ miscarriage / premature
labor
Greater distribution volume due to increase in blood
volume
More prone to hypoxemia due to decrease in FRC and
increase in O2 consumption
62. Contd…
Difficult airway due to wt. gain, soft tissue in the neck,
breast enlargement, and laryngeal edema
Relatively safe in 8-24 wks of pregnancy.
Chances for damage to gravid uterus by Verees needle
Fetal acidosis common
63. SAGES recommendations for safe
lap in pregnancy
Operation in 2nd trimester before 24 wks
Tocolytics therapy if risk of preterm labor
Open laparoscopy for abdominal access (HASSON’S TECH) to
avoid damage to gravid uterus
IAP less than 12mmHg
Continuous Fetal heart monitoring with trans vaginal USG
PaCO2 to be maintained at normal levels with the help of
EtCO2 monitor/ABG
Mechanical ventilation to maintain physiologic maternal
alkalosis (pH7.44)
Pneumatic compression devices to calf muscles to prevent
DVT
*(SAGES- society of American Gastrointestinal and
Endoscopic surgeons)
64. Postoperative management
All patients should receive supplemental oxygen.
This helps to mitigate the effects of pneumoperitoneum
on respiratory function.
Alveolar recruitment techniques, using short-term
continuous positive airway pressure or high flow oxygen
delivery systems may be used.
Refered Shoulder pain-generaly resolves after 30 to 60
minutes. Diaphragmatic irritation d/to gas used to creat
pneumoperitonium.