Anesthetic management of a patient with COPD posted for Laparoscopic Cholecystectomy - case discussion

1. Anaesthetic management for
Laparoscopic Cholecystectomy
in a patient with COPD
Dr. Pallab Kanti Nath
MD Anaesthesia
Senior Resident
Department of Anaesthesiology
Medical College, Kolkata

2. Summary of the case
NAME : Mr. Pulak Dutta
AGE/SEX : 62 YRS/ MALE
Address : LP. 64/2, Birati
Occupation : Carpenter
Education :Studied upto Class X
DATE OF ADMISSION : 25/11/15

3. Chief complaints
• Pain abdomen off and on for last 4 months
• Fever for last 3 days
• Three episodes of vomiting on the day of admission

4. Initial Management
 Initially Patient was seen by local physician
 Diagnosed as a case of acute cholecystitis with cholelithiasis
 Patient received antibiotics (ciprofloxacin/metronidazole),
analgesics (PCM, Drotaverine), Pantoprazole and Ondansetron
 Later patient was referred to Medical College, Kolkata for further
management
 In Medical College, Patient was continued on the conservative
management and planned for Laparoscopic cholecystectomy

5. Comorbidity
 Cough and wheeze: off and on for last 5 years
 Further questioning revealed:
 Smoker for last45 years
 20 /day, now reduced to ~10
 Increased cough, expectoration from last week
 currently taking Salbutamol puffs, ipravent puffs and budenoside
inhaler (local physician consultation)
 Can climb 2 flights with difficulty – gets breathless
 Clinically RS : barrel chest, wheeze and ronchi present
 CVS NAD on examination

6. • B.P : 138/86mmHg
• PULSE : 88/min, regular, (arterial wall palpable)
• RESPIRATION : 20b/m
• TEMPREATURE : 36.6 c
• SpO2 : 92% (room air)
• Body wt :65 kg

7. Investigations available at PAC visit:
Blood:
Hb – 13gm/dl
TC:
RBC- 5.8* 10^6/ul
WBC- 16,000/ul
DC – 42(N), 38(L), 11(M), 9(E)
BILIRUBIN (TOTAL) 1.7 mg/ dL
BILIRUBIN (DIRECT) 1.0 mg/ dL
BILIRUBIN INDIRECT 0.7 mg/ dl
SGPT- 97, SGOT – 102,
Alk Phos – 205
Ur/Cr, Sodium/Potassium, Blood
Glucose(F/PP)- NAD
USG – Calculus Cholecystitis
ECG - NAD
CXR:
• increased bronchovascular markings
• flattened hemidiaphragms(bilat)

8. Plan of management:
Patient of Acute Calculus Cholecystitis
with Acute on Chronic COPD
Posted for Laparoscopic Cholecystectomy

9. Discussion
•COPD
•Laparoscopic Surgery
Anaesthetic implication
And management

10. COPD

12. Pathophysiology of COPD
 Increased mucus production and reduced
mucociliary clearance - cough production
 Loss of elastic recoil - airway collapse
 Increase smooth muscle tone
 Pulmonary hyperinflation
 Gas exchange abnormalities - hypoxemia
and/or hypercapnia

13. Airspace collapse
Low V/Q
Hypoxia
Airway narrowing
Alveolar hypoventilation
Hypoxia in
COPD
AJRCCM 2001; 163: 283-91

14. Causes of Hypercapnia in COPD
Inspiratory muscle
fatigue
V / Q
Mismatch
Reduced ventilatory response
to CO2

15. Chronic hypoxia
Pulmonary vasoconstriction
Muscularization
Intimal
hyperplasia
Fibrosis
Obliteration
Pulmonary hypertension
Cor pulmonale
Death
Edema
Pulmonary Hypertension in COPD
Source: Peter J. Barnes, MD

16. Polar forms of COPD:
CHRONIC BRONCHITIS
 Chronic bronchitis is defined by a productive cough on
most days for at least three months for at least two
consecutive years and which cannot be attributed to
other pulmonary or cardiac causes.

17. Polar forms of COPD:
EMPHYSEMA
 Emphysema is characterised by destruction of alveolar
walls, resulting in abnormal enlargement of airspaces
and loss of lung elasticity, with consequent obstruction
of peripheral airways.

18. Lung Volumes in COPD

19. Differences Between COPD and Asthma
Parameters COPD Asthma
Onset Mid-life Early in life (often
childhood)
Symptoms Slowly progressive Vary from day to day and
peak in the night/early
morning
History Long smoking history or
exposure to smoking and
bio-mass fuel
History of allergy, rhinitis
and/or eczema.
Inflammatory cells Neutrophils Eosinophils
Airway
hyperresponsiveness
Absent Present
Airflow limitation Largely irreversible
usually < 15% or 200 ml
change
Largely reversible
usually > 15% or 200 ml
change.

20. Extrapulmonary comorbidities in COPD
 Commonly seen
 Weight loss
 Nutritional abnormalities
 Skeletal muscle dysfunction
 Increased risk of
 Myocardial infarction
 Angina
 Osteoporosis, bone fractures
 Respiratory infection
 Depression
 Diabetes
 Sleep-disorders
 Anemia
 Glaucoma
 Common consequences
 RVH
 Cor pulmonale

21. Laparoscopic Cholecystectomy
Advantages…….
“minimally invasive”
“ minimal access”

22. Reduced stress response
 Reduced acute phase reactants; CRP, IL 6
 Reduced metabolic response; N2 balance & immune
function better preserved
 Not much reduction in endocrine response; Plasma
cortisol, catecholamines similar (pain, discomfort from
peritoneal stretch, hemodynamic dist, vent changes)

23. Reduced pain and analgesic
requirements
 Less acute pain
 Shorter duration of pain
 Less analgesic consumption
 Smaller incision; less superficial trauma
 More of visceral pain, shoulder tip pain

24. Decreased postoperative respiratory
dysfunction
 Less pain
 Less atelactasis, less respiratory infection
 Diaphragmatic function impaired but less than after
laparotomy
 Pulm fn less impaired (30-38% less than lap)

25. Pneumoperitoneum
• Abdominal insufflation w/ CO2, helium, nitrous oxide, or
oxygen to ~ 15 mmHg
– Normal Intra-abdominal pressure (IAP) < 5 mmHg
• CO2 most commonly used gas.
– Noncombustible = safe to use with electrosurgical devices
– Solubility in blood and reactivity w/ soluble buffering systems
minimize the risk of gas emboli (
)
• Systemic absorption thought to be facilitated by CO2
specific widening of inter-cellular junctions in peritoneum 
buffering of CO2 as above  Systemic Acidification

26. Pathophysiological effects of
laparoscopy
Due to
- creation of a pneumoperitoneum
- positioning

27. Effects of Pneumoperitoneum...
 ……. created by intraperitoneal insufflation of
CO2 at 1-6 lpm
- Respiratory
- CVS
- regional blood flow
- dysrhythmias
- GIT
- hypothermia

28. Respiratory Effects
1. Changes in ventilation
2. Increase in PaCO2
3. Endobronchial intubation
4. CO2 subcutaneous emphysema
5. Pneumothorax
6. Gas embolism

29. Changes in Ventilation
  compliance (30-50% )
thoracopulmonary
  in FRC (elevation of
diaphragm)
  airway pressure 
 changes in distribution of
ventilation & perfusion
*IAP 15 mmHg exerts pressure 50 kg
on diaphragm

30. Increase in PaCO2
  s to reach plateau in 15-30 mins
  depends on IAP
 EtCO2 plateaus after
25-30 mins
 Any rise after that
– search for cause !

31. Causes for  PaCO2
1. Absorption from peritoneal cavity- diffusibility,
area, perfusion
2. V/Q mismatch; abdominal distention, patient
position, mechanical ventilation,  CO
3. Depression of ventilation by anaesthetics if
spontaneously breathing
4.  metabolism ( light anaesthesia, MH)
5. Complications; CO2 emphysema, capnothorax,
CO2 embolism, endobronchial intubation

32.  10-25%  in alveolar ventilation for normocapnia
 Remains unchanged if under LA ( MV s)
 EtCO2 is an imperfect index of PaCO2 if  dead space
ventilation ( PaCO2 may be high despite normalization of
EtCO2 by increasing MV)
 In ASA class II/III pts - poor correlation b/w PaCO2 &
EtCO2

33. Other Respiratory Effects
Endobronchial Intubation
Due to cephalad displacement of diaphragm  cephalad
displacement of carina   Paw,  SpO2
4. S/c Emphysema
5. Pneumothorax
6. Gas embolism

34. Cardiovascular Effects
 Peritoneal insufflation to IAP > 10 mmHg (in normal pts) for
significant alterations in hemodynamics
Biphasic effect on Cardiac Output
Initial transient  due to splanchnic compression (IAP<15)
Then  CO (10-30%)
Due to
-  venous return
To attenuate
- Fluid loading pre &
intraoperatively
- Head low before insuffln
- Pneumatic compression
- Elastic bandage legs

35.   SVR
Due to;
- direct compression abdominal aorta & abdominal
organs
- Reflex symp response to  CO
- Release of neurohumoral factors vasopressin,
catechols, renin-angiotensin
  PVR
 HR slight , unchanged
  arterial BP despite  CO

36.  IntraAbdominal Pressure
Pooling of
blood legs
caval
comp
Vn
Res
 I/thoracic pr peritoneal
recs stimn?
vasc res
aorta &
abdal
organs
Neurohumoral factors
 Venous
return
 inotropism?  SystemicVasc Res
 Cardiac Output  Arterial pressure

37. Cardiac arrhythmias
 Reflex ’s in vagal tone sudden peritoneal stretch 
bradycardia, arrhythmias, asystole
- Stop insuffln, atropine, deepen anaesthesia
  PaCO2 ? May not correlate
 Use of halothane
 Pts with cardiac disease
 Gas embolism
 hypoxia

38. GIT Effects
 Due to  intra abdominal pressure ?? ?  risk
of aspiration
BUT
Changes in LES tone  maintenance of pressure gradient
across GE junction   risk of regurgitation
 Head down position prevents regurgitated material from
entering the airway

39. Hypothermia
 Significant heat loss may occur
 Due to – insufflation of cold gases
 Temperature of gases
 Rate of gas flow
 Leakage through the ports etc

40. Positions in laparoscopic surgeries
 Trendelenburg / head down;
pelvic, inframesocolic surgery
 Reverse Trendelenburg / head up;
supramesocolic surgery
 Lateral
 Lithotomy

41. Effects of Positioning……
 Crdiovascular
 Respiratory
 Nerve and other injuries
 Care of eyes, iv lines, ETT etc

42. HEAD DOWN
 CVS effects;
-  CVP
-  CO
- Systemic vasodilation & bradycardia due
to baroreceptor reflex to  hydrostatic pr.
-  transmural pressure in pelvic viscera 
 blood loss,  gas embolism

43.  Respiratory effects;
- Atelactasis
-  FRC, TLC
-  pulmonary compliance
 Cerebral circuln
-  CBF   ICP ( low compliance)
 IOP - 

44. HEAD UP
 CVS effects;
-  venous return
-  CVP
-  CO
-  MAP
 Resp ; less significant changes
 Venous stasis ; aggravated if lithotomy
compound
hemodynamic
changes due to
pneumoperitoneum

45. Nerve injury
 Potential hazard
 Avoid overextension arms, use shoulder braces with
caution, no impingement on brachial plexus
 Lower limb palsies especially peroneal neuropathy,
meralgia paraesthetica, femoral neuropathy
 Common peroneal n. - lithotomy

46. Preoperative Evaluation
 Absolute C/I rare, include;
- ICP ( tumor, hydrocephalus, head injury)
- hypovolaemia
- VP shunt
- peritoneo-jugular shunt
- ? Glaucoma
- ? Severe CHF, severe VHD

47. Anaesthetic management
 Calculus cholecystitis
 COPD
Posted for Laparoscopic
Cholecystectomy

48. Preoperative workup
 Complete hemogram
 Serum electrolytes
 Urine analysis
 Electrocardiogram
 Chest x-ray
 PFT including ABG
 ECHO

49. Indications for PFT:
 Patients in whom risk of surgery is high
 Patients needing specialised postop respiratory care
 Surgery should not be denied on the basis of abnormal
PFT

50. Assessment of Severity
(Spirometry)
Mild Moderate Severe Very severe
FEV1/ FVC
<70%
FEV1
>80%
FEV1/ FVC
< 70%
FEV1
50% - 80%
FEV1/ FVC
<70%
FEV1
30% - 50%
FEV1/ FVC
<70%
FEV1< 30%
or chronic
respiratory
failure or right
heart failure

51. PFT predictors of increased risk
 FVC < 50% predicted
 FEV1 < 50% predicted or < 2L
 MVV < 50% predicted or < 50L/min
 DLCO < 50% predicted
 RV / TLC > 50% predicted
Nunn and Milledge criteria:
 FEV1 < 1L, PaO2 normal, PaCO2 Normal : Low Risk
 FEV1 < 1L, PaO2 low, PaCO2 Normal : prolonged O2
 FEV1 < 1L, PaO2 low, PaCO2 High: Ventilation

52. Preoperative Preparation
 Stop smoking
 Improves mucociliary function, decreases sputum production and
airway reactivity : 2 months
 Reduce CO levels : 12 hours
 Bronchodilators
 Control of infection
 Chest physiotherapy, hydration
 Familiarise patient with deep breathing exercises and respiratory therapy
equipment that are likely to be used postop
 Improve oxygenation
 Steroids
 Diuretics, digitalis

53. Smoking cessation & time course
Time course Beneficial effects
12 – 24 hours CO & nicotin levels
48 – 72 hours COHb levels normalise & airway
function improve
1-2 weeks Sputum production
4 – 6 weeks PFTs improved
6 - 8 weeks Immune function & drug metabolism
normalise
8 – 12 weeks Overall postop morbidity

54. Perioperative steroids? Which patients?
What are equivalent doses of steroids?
 Long-term steroids >10 mgs prednisolone daily
 Pts on steroids >10 mgs daily, in last 3 months.
 Pts on high dose inhalation steroids
 Prednisolone 5 mgs is equivalent to
 Betamethasone 750 microgms
 Cortisone acetate 25 mgs
 Dexamethasone 6 mgs
 Hydrocortisone 20 mgs
 Methylprednisolone 4 mgs

55. Recommendations for perioperative steroids
Dose Surgery Recommended dose
<10
mg/day
Minor /
Moderate /
Major
Additional steroid cover not required (assume
normal HPA response)
>10
mg/day
Minor surgery 25 mg of hydrocort at induction & normal
medications post-op
>10
mg/day
Moderate
surgery
Usual dose pre-op & 25 mg hydrocort IV at
induction then 25 mg IV TDS for 1day then
recommence pre-operative dosage
>10
mg/day
Major surgery Usual dose pre-op & 100 mg hydrocort at
induction then 100 mg IV TDS for 2-3 days.

56. Monitoring
 HR, continuous ECG
 Intermittent BP
 EtCO2
 SpO2
 Temp
 Intra abdominal pressure
 Airway pressure, Expired tidal and minute volume
 IBP, ? CVP,? PCWP – patients with heart disease
 TEE - pts with more severe heart disease
 ABG- as Δa-EtCO2 - pts with severe heart disease
 Hourly urine output

57. Choice of Anaesthesia
General Anaesthesia
 Allows control of ventilation, excellent muscle
relaxation
 Ensures oxygenation and CO2 elimination
 IPPV overcomes decrease in lung compliance,
increased resistance and decreased FRC
 Comfort to patient, prolonged procedures

58. GA specifics for Laparoscopy
 Preloading prior to pneumoperitoneum
 Decompress stomach / bladder
 Smooth induction and release of pneumoperitoneum
 Keep IAP as low as possible; IAP < 12- 15 mmHg
 Positioning; head low prior to insufflation
Minimise tilt < 20°; slow

59. Ctd……..
 Check ETT after positioning
 Adjust ventilation to maintain EtCO2 about 35 mm Hg by
 MV by 15-25%
 Adequate anaesthesia depth
 Omission of N2O may improve surgical condns
 Consider use of vasodilators like nicardipine, 2 agonists,
remifentanil

60. Regional anaesthesia
 Avoids risk of bronchospasm due to intubation
 Excellent intraoperative and postoperative analgesia
 Problems
 Spontaneous ventilation may lead to hypoventilation
 Hypercarbia and acidosis can increase PVR
 Inadequate muscle relaxation, coughing / bucking
 High levels of spinal / epidural block
 Increase parasympathetic tone and cause bronchospasm
 Decrease ERV by ~50%, detrimental for active expiration
 Hypotension
 Prolonged procedure, patient discomfort, shivering
 Heavy sedation may be worse than light GA

61. My choice for this case
 GA combined with epidural analgesia
 All benefits of GA
 Excellent analgesia with epidural
 Reduced requirement of muscle relaxants
 Lower risk of hypotension
 Postoperative analgesia without excessive systemic
narcotics
 May facilitate early ambulation
 Better performance of respiratory therapy manoeuvres
 May reduce postoperative pulmonary complications
 May reduce risk of DVT

62. Premedication
 Steroid hydrocortisone 100mg iv
 Salbutamol 2 puffs, ipratropium 2 puffs, budenoside 2
puffs before sending to OT
 Atropine
 Decreases airway resistance
 Decreases secretion-induced airway reactivity
 Decreases bronchospasm from reflex vagal stimulation
 But can cause drying of secretions, mucus plugging
 Small dose of benzodiazepine acceptable
 Avoid H2 receptor antagonists

63. Induction
 Avoid thiopentone
 Thiobarbiturates may cause histamine release
 Prefer oxybarbiturates (methohexitone)
 Airway instrumentation or other stimulation under light thiopentone
anaesthesia may provoke bronchospasm
 Ketamine
 Tachycardia and HT, may increase PVR
 Agent of choice in unstable / wheezing patient
 Propofol
 Offers marked protection from bronchospasm
 But watch for hemodynamic compromise
 Agent of choice in stable patient

64. Intubation
 NDMR – vecuronium, rocuronium preferred
 IV lignocaine prior to laryngoscopy and intubation
 Narcotic
 Deep plane of anaesthesia prior to intubation
 LMA avoids tracheal stimulation (LMA Proseal – Laparoscopy)

65. Maintenance
 IPPV
 Muscle relaxant
 Avoid atracurium, mivacurium
 Prefer Vecuronium, pancuronioum, rocuronium
 Inhaled agent
 Halothane most potent bronchodilator (< 1.7 MAC)
 Isoflurane comparable at higher MACs
 Irritant smell may provoke bronchospasm
 Narcotic
 Fentanyl
 Morphine, pethidine may cause histamine release

66. End of Anaesthesia
 Any problems anticipated during reversal?
 Neostigmine may provoke bronchospasm
 Atropine 1.2-1.8mg or glycopyrrolate 0.6mg before
neostigmine
 Extubation : deep or late, awake?
 Deep extubation may reduce chance of bronchospasm
 But in this case delayed extubation may be preferred
 May require a period of postoperative ventilation
 Awake, obeying commands
 Sustained head lift
 Adequate gas exchange

67. Postoperative management
 Admit patient into a ICU if ventilated
 HDU if not ventilated
 Controlled Oxygen therapy
 Provide good postoperative pain relief
 Postoperative respiratory therapy
 Encourage lung inflation manoeuvres
 Ambulate as early as possible to prevent pulmonary
morbidity and other complications (such as DVT and
PTE)

68. Postoperative problems common with
Laparoscopy
 Pain
 PONV(40-75%)
 Lung fns-diaph dysfn (residual pneumoperitoneum,
phrenic n neuropraxia)
 Oxygen therapy

69. Pain relief
 More visceral than somatic pain
 Higher IAP –more pain
 LA infiltration- intraperitoneal, port site
 Shoulder pain - careful evacuation of residual CO2
 Preoperative NSAIDs
 Intra & post operative opioids
 Use multimodal analgesia

70. Postoperative pulmonary complications
 Decreased FRC
 Large incision
 Postoperative pain
 Splinting of the diaphragm
 Decreased sputum clearance
 Atelectasis, Pneumonia
 Mechanical ventilation, prolonged ICU / hospital stay
 Delayed ambulation
 DVT, PE
 Cor pulmonale

71. Complications of laparoscopy
 PONV
 Shoulder pain
 Surgical instrumentation - misplacement Verress
needle, concealed hge, stomach & bladder injury
 CVS; collapse, vasovagal, dysrhythmias, mc dysfn, gas
embolism
 Pulmonary; hypoxia, hypercapnia, endobronchial
intubation, pneumothorax, pneumonia,
pneumomediastinum, s/c emphysema
 Nerve injuries – improper positioning
 ICP ; IOP
 DVT

72.  Subcutaneous emphysema;
extraperitoneal insufflation – accidental/ intentional
 Pneumomediastinum, pneumopericardium;
 Pneumothorax ;
Capnothorax
-Embryonic channels/ peritoneopleural ducts  right side
- Defects in diaphragm,weak points in oesophageal & aortic
hiatus
- Pleural tears at level of GE junction left side
- Rupture of emphysematous bullae Pneumothorax

73. Thank You