This presentation encapsulates how to proceed with anaesthesia for pelvic endoscopies. It outlines the do's and the dont's for these simple set of procedures which can turn into a nightmare if handled in an off-hand way.

1. Dr. Atul Dixit, MD
Professor of Anaesthesiology
Mohak Hi-Tek Hospital & Infertility Centre
Indore MP.
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2.  The world over, Intervention for infertility &
Endoscopic surgery for gynaecology has
evolved: gone to the next level
 Patients are demanding these procedures,
which had to be hard-sold to them about 5
years back
 Anaesthesiology has kept pace with the
demands of this branch of surgery
 Also, Indian surgeons have come out of their
comfort zone & embraced these procedures
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3. Taking care of the haemodynamic changes
caused by:
 Hysteroscopy: Plays havoc with electrolytes!
◦ NS infusion for visualisation of inside of uterus
◦ Glycine infusion for TCRE, myomectomy, resection
of septum, adhesiolysis
 Laparoscopy: Plays havoc with gases!
◦ carbo-peritonium which is a must for proper
visualisation of the contents
◦ Position: steep Trendelenburg
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4.  Rule out & out-source to your team:
◦ Anaemia (tendency to develop pulmonary oedema)
◦ Hypo-thyroidism: if detected, wait, treat & take in
OT: cardiovascular collapse
◦ Concomitant viral or other infections: Platelets!!
◦ Asthma, diabetes
◦ Administration of steroids in the past
◦ Problem with teeth, nasal sinuses, tonsils
◦ Discourage ornaments, mehndi, nail polish
◦ Hypertension, ischemic heart disease, angina
◦ Pulmonary Artery Hypertension (PAH) in the obese
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5. The Basics:
 Secure angio-access: 18G canula is a must
 No IV fluids for short duration diagnostic
procedures
 NS 1000ml if patient tends to keep a low BP
 RL 1000ml if IPPV is used for procedures
lasting more than an hour
 Liberally use paracetamol, diclofenac &
tramadol HCL suppositories
 Spinal anaesthesia usually discouraged
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6.  If diabetic, do a RBS prior to the procedure
 If on thyroxin, anti-hypertensives, coronary
vasodilators, anti-epilectics, anti-asthmatics
administer early in the morning with sip of
water. Do not discontinue
 Discontinue aspirin
 Boost self esteem of the subject
 BP of most patients shoots up during shifting
and prior to the procedure!
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7.  IV glycopyrrolate 0.2 mg + fentanyl 100µgms
 IV Propofol 1% 1.5-2 mg / kg (for hypnosis)
 IV Succinylcholine 1.5–2 mg / kg (for intubation)
 Rusch cuffed endotracheal tube 6.5 – 7 – 7.5mm
OD
 Oxygen, Nitrous Oxide, Sevoflurane by circle
system & ventilator of work station
 Tape the eyes
 EtCO2 monitoring is an absolute must
 IV atracurium or vecuronium for relaxation
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8.  NIBP measurements at 5 minute intervals
 Close watch on EtCO2: it is directly connected
to hypertension, more bleeding from the site
& increases chances of pulmonary oedema
 Acceptable EtCO2 levels are 27-32mm of Hg
 Frequent change of soda lime in circle
absorber
 IV clonidine 30µgms bolus till BP 100-110
mm of Hg systolic. Think of nitroglycerine!
 IV esmolol 2-4 mg bolus till heart rate rests
at 90-100 per minute
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9.  Good anaesthesia workstation with circle
system, ventilator & vaporizer
 Good multi-parameter monitor with E/R/N/S
 EtCO2 channel: do not work without it
 Laryngeal mask airways for short procedures
lasting 30 mins.
 Endo-tracheal intubation in others
 Glucometer for RBS on the table
 Facility for blood gas & electrolyte
measurement
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10.  One lung intubation or accidental extubation
due to the steep head low tilt
 Push due to the assistant may kink the tube
 Air-embolism
 Subcutaneous emphysema
 Nerve damage to femoral N or brachial plexus
 Corneal ulcers
 Hypertension
 Electrolyte abnormalities
 Unexplained hypotension
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11. 2012
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Old description of the Trendelenburg position

12. .
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Good Luck!
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