Skip to main content

laparoscopy..missed hazards


It is theoretically sound to avoid N2O during laparoscopy for at least two reasons:
First, it diffuses into the abdominal cavity in concentrations sufficient to support combustion of intestinal gas.1
second, it will diffuse into CO2 bubbles and emboli,increasing their size and potenial for an obstructive event.
Adequate muscle relaxation is required during laparoscopy so that:
Spontaneous respiratory effort does not impair the surgical procedure or risk increasing the gradient for embolic gas to enter the central circulation
Most studies but not all report a decrease in left ventricular function and cardiac output (cardiac output decreased 7–24%).
In addition, with assumption of the reverse Trendelenburg position, cardiac index may decrease by 50% of preanesthesia and preinsufflation values.
Venous stasis of the lower extremities also occurs, with attendant concerns for embolic phenomenon 3,4
Relatively small CO2 emboli have been detected by transesophageal echocardiography in 69% of patients, classified by the American Society of Anesthesiologists as physical status ASA1 to ASA3, who undergo laparoscopic cholecystectomy.5
Fatal massive CO2 embolism has been reported, including a report of death from delayed CO2 embolism associated with gas trapping in the portal circulation .6
1-Diemunsch PA, Torp KD, Van Dorsselaer T et al. Nitrous oxide fraction in the carbon dioxide pneumoperitoneum during laparoscopy under general inhaled anesthesia in pigs. Anesth Analg. 2000;90:951–3.

2-Neukman GG. Laparoscopy explosion hazards with nitrous oxide. Anesthesiology 1993;78:875.
3-Celli BR, Rodriques KS, Snider GL. A controlled trial of intermittent positive pressure breathing, incentive spirometry, and deep breathing exercises in preventing
pulmonary complications after abdominal surgery. Am Rev Respir Dis 1984;130:12.
4-Millard JA, Hill BB, Cook PS, et al. Intermittent sequential pneumatic compression in prevention of venous stasis associated with pneumoperitoneum during
laparoscopic cholecystectomy. Arch Surg 1993;128:914.
5-Derouin M, Couture P, Boudreault D,et al. Detection of gas embolism by transesophageal echocardiography during laparoscopic cholecystectomy.
Anesth Analg 1996;82:119.
6-Lantz PE, Smith JD. Fatal carbon dioxide embolism complicating attempted laparoscopic cholecystectomy: case report and literature review.
J Forensic Sci 1994;39:1468.

Labels

Labels:

Comments

Post a Comment

Popular posts from this blog

Driving Pressure in ARDS: A new concept!

Driving Pressure and Survival in the Acute Respiratory Distress Syndrome Marcelo B.P. Amato, M.D., Maureen O. Meade, M.D., Arthur S. Slutsky, M.D., Laurent Brochard, M.D., Eduardo L.V. Costa, M.D., David A. Schoenfeld, Ph.D., Thomas E. Stewart, M.D., Matthias Briel, M.D., Daniel Talmor, M.D., M.P.H., Alain Mercat, M.D., Jean-Christophe M. Richard, M.D., Carlos R.R. Carvalho, M.D., and Roy G. Brower, M.D. N Engl J Med 2015; 372:747-755 February 19, 2015 DOI: 10.1056/NEJMsa1410639 BACKGROUND Mechanical-ventilation strategies that use lower end-inspiratory (plateau) airway pressures, lower tidal volumes (V T ), and higher positive end-expiratory pressures (PEEPs) can improve survival in patients with the acute respiratory distress syndrome (ARDS), but the relative importance of each of these components is uncertain. Because respiratory-system compliance (C RS ) is strongly related to the volume of aerated remaining functional lung during disease (termed functional lung size)...
5 comments
Read more

Anaphylaxis updates part 2- Empty Ventricle Syndrome

Patients with anaphylaxis should not suddenly sit, stand, or be placed in the upright position. Instead, they should be placed on the back with their lower extremities elevated or, if they are experiencing respiratory distress or vomiting, they should be placed in a position of comfort with their lower extremities elevated. This accomplishes 2 therapeutic goals: 1) preservation of fluid in the circulation (the central vascular compartment), an important step in managing distributive shock; and 2) prevention of the empty vena cava/empty ventricle syndrome, which can occur within seconds when patients with anaphylaxis suddenly assume or are placed in an upright position. Patients with this syndrome are at high risk for sudden death. They are unlikely to respond to epinephrine regardless of route of administration, because it does not reach the heart and therefore cannot be circulated throughout the body
Post a Comment
Read more

Epidural catheter tests...not only the test dose

Siphon test The catheter is held upright and a fluid level sought. If the catheter is then elevated, the fluid level should fall (see inset) as the fluid siphons in to the epidural space, which is usually under negative pressure compared with atmospheric. If the fluid column continues to rise, this may suggest subarachnoid placement. The siphon test can be reassuring, but is not mandatory. Aspiration  This should be considered mandatory. The Luer connector is attached to the catheter and a syringe is used to apply negative pressure. Free and continued aspiration of clear fluid can indicate subarachnoid placement of the catheter. However, if saline has been used for loss of resistance, it is not unusual for a small amount of this to be aspirated. If there is doubt, the aspirated fluid can be tested for glucose (cerebrospinal fluid will generally test positive) or mixed with thiopentone (cerebrospinal fluid forms a precipitate). If blood is freely and continuously aspirated, this sug...
Post a Comment
Read more