Total Intravenous Anaesthesia ( TIVA) for Laparoscopic Day Surgery

Transcription

Total Intravenous Anaesthesia
( TIVA) for Laparoscopic
Day Surgery
Dr. H. Metwally
Department of Anaesthesia,
Diana, Princess of Wales Hospital,
Grimsby, UK
Dr. H. Metwally
Diana Princeses of Wales Hospital
www.LincsPainClinic.com
Dr. H. Metwally
Dr. H. Metwally
Why Day Surgery?
 The patient has a planned procedure at a guaranteed time with






no cancellations because of emergencies.
Recovering at home also cuts the risk of picking up a hospital
acquired infection.
Most operations can be carried out sooner and are much less
likely to be cancelled if you are able to have day surgery.
Many people like to spend as little time in hospital as possible
and prefer to be at home with their family or friends.
There is less disruption to your daily routine, childcare is easier
to plan and very often you will be back at work sooner.
Improved utilization of general surgeon in local clinic and clinic´s
facilities.
Potential advantage of day surgery are cost saving,
Dr. H. Metwally
Why TIVA?
 Quick patient
recovery of
postoperative
psychomotor
performance.
 Obviates the use of
N2O
 Decrease of PONV in
the post-operative
period.
Dr. H. Metwally
Cost of TIVA
 the cost of TIVA can also be
decreased if a single pump
and infusion pump sets are
used.
 The cost of TIVA with
propofol was less than
SEVO or DES anesthesia
and moreover, propofol TIVA
offered benefit of faster
recovery in the study.
PMID: 18251240 [PubMed - indexed for MEDLINE, 2007
Dec;45(4):205-10.
Dr. H. Metwally
Total Intravenous Anaesthesia
 Haemodynamic stability
 Controlled ventilation
without muscle
relaxants
 Good recovery profile
 Low incidence of PONV
 Excellent patient
satisfaction
Juckenhofel et al Anaesthetist.
48(11):807-12 Nov 1999
Chung et al Acta Anaes Scandinavica
44(7):790-8 Aug 2000
Dr. H. Metwally
TIVA in Day Surgery
Dr. H. Metwally
Laparoscopy in Day Surgery
 10-25% of day surgery patients
8.9% of all day case procedures in last year in our
hospital ( 601/6780)
 Significant intra-operative and post-
operative problems
 High rate of unplanned admissions
5.3% overnight hospital admission rate
Hedayatti et al., BJA 83(5):776-9 Nov 1999
Dr. H. Metwally
Unplanned Admission
 Factors contributing to unplanned admission:
- PONV(61%)
- Pain (15%)
- Urinary retention (9%)
- Dizziness (5%)
- Misc... ( 10%)
 Anaesthesia direct contributing factor
Hitchcock et al Anaesthesia for day surgery Br J Hosp Med
1995; 54:202-6
Dr. H. Metwally
Aims
 To evaluate TIVA
- Ability to provide controlled ventilation without muscle relaxants
- Operating conditions
- Side-effects
- Awakening time
 To evaluate the PONV rate
 To assess the quality of post-operative analgesia
 To evaluate the unplanned hospital admission
rate
Dr. H. Metwally
Anaesthetic Technique
 Pre-assessment
 Induction & maintenance with Propofol TCI
TM
and Remifentanil: controlled ventilation with O2
and air via LMA
 Post-operative pain control: balanced
analgesia diclofenac premedication, pethidine
intra-operatively ± in recovery, co-codamol,
tramadol
 Antiemesis: prophylactic anti-emetic
ondansetran
(droperidol) and prochlorperazine
Dr. H. Metwally
Distribution of Patients’ Age
 Mean age:
32.34±1.68years
60
50
 Range: 17-57 years
40
Age in
Years
30
 12/83 (14.46%) were
20
over 40 years
10
0
Patients Number
3-D Column 1
Dr. H. Metwally
ASA Status
 ASA I : 62/83 ( 73%)
ASA STATUS
Slice 2
27%
 ASA II : 21/83 ( 27%)
Slice 1
Slice 2
Slice 1
73%
Dr. H. Metwally
Distribution of weight
 Mean weight:
Slice 3
23%
Slice 4 Slice 1
6%
13%
Slice 1
Slice 2
Slice 2
58%
72.88 ± 3.5 kg
 Range: 47-124 kg
 < 50 kg (slice 1)- 6%
51-70 kg (slice 2) -58%
71-90 kg (slice 3) -23%
> 90 kg (slice 4) - 13%
Slice 3
Slice 4
Dr. H. Metwally
Type of Procedure
Type of operations
 Laparoscopic
40
40
35
30
25
25
20
No.of
20
patients
15
15
10
5
sterilization - 15%
 Diagnostic laparoscopy
- 40%
3-D Column 1  Diag.Laparoscopy +
hysteroscopy - 25%
 Hernia Repair – 20%
0
Lap.Ster
Dr. H. Metwally
Diag.Lap +
hyst.scopy
Technique
 Propofol Cpt 2-6




mcgm/ml
Remifentanil Cpt 2-6
nanogm/ml
Mivacurium 100-150
mcgm/kg one dose
LMA (Proseal) or ETT
IPPV/Pr.Cont/1220CmH20>>Vt.~550ml
X12/min
Dr. H. Metwally
Dr. H. Metwally
Group
Duration
(min.)
Propofol
(mg/kg/hr)
Remifentanil
(g/kg/min.)
Laparoscopic
sterilization - 15%
34.28  1.14
12.15  0.32
0.24  0.01
Diagnostic
laparoscopy - 40%
33.09  1.80
12.27  0.60
0.26  0.02
Diag. Laparoscopy +
hysteroscopy - 25%
30.06  1.12
12.17  0.50
0.25  0.01
Hernia Repair – 20%
33.06  1.34
12.23  0.60
0.25  0.05
All Laparoscopies
n=83
33.04  1.32
12.34  0.54
0.25  0.02
Dr. H. Metwally
Peak Airway Pressure
40
35
30
25
cm of water
20
15
10
5
0
3-D Column 1
Dr. H. Metwally
Patient number
Awakening Time
 Mean: 10.04±0.49 min
Slice 3
29%
Slice 4
10%
Slice 1
16%
 Range: 1 - 23 min
 < 5 min - 16%
Slice 2
45%
Dr. H. Metwally
6-10 min - 45%
11-15 min -29%
> 15 min - 10%
Side- Effects
0.05
0.048
0.045
0.036
0.04
0.035
0.03
0.025
3-D Column 1
0.02
0.015
0.01
0
0.005
0
0
Hypotension
Dr. H. Metwally
Bradycardia
Pt.movement
Regurgitation
PONV
 Incidence ranges from 40 -77%
Bailey et al Anesthesiology 1990
Hovorca et al can J Anesthesiology 1989
Madej et al BJA 1986
 PONV is significantly lower with TIVA
Chung et al Acta Anaesthes Scandinavica 2000
 Balanced antiemesis is more effective
David J Rowbotham Editorial BJA 2000
Dr. H. Metwally
PONV
 Overall PONV rate
8
7
was 9.64%
 2 patients in recovery
and 1 patient in ward
required rescue
antiemetic (3.6%)
 Only 1 patient had
severe PONV needing
hospital admission
1.2
6
5
%4
2.4
6
3
2
2.4
1
0
Recovery
Dr. H. Metwally
Ward
Vomiting
Nausea
Post-operative Pain
 Severe and prolonged after lap. Sterilisation
Alexander JI Pain after laparoscopy BJA 1997: 79: 369-78
 Multi-modal analgesia more effective and
reduces morbidity
Dr. H. Metwally
Post-operative Pain
 Pain score > 7
12
10
10
6
4
Pain scores
8
Lap. Ster - 27.3%
Diag.Lap - 16.4%
6
3.73
2.98
2
1.36
 Pethidine (mean±sem)
1.09
PAIN SCORE
>7
PAIN ON
DISCHARGE
PAIN ON
ADMISSION
0
Intra-op: 36.24 ± 1.3 mg
Recovery: 27.43 ±
5.9mg
Lap. Ster
Diag.Lap
Dr. H. Metwally
Obesity
 ‘BMI > 30 unsuitable for day surgery’
Guidelines for day surgery royal college of surgeons of England 1992
 ‘Obesity alone should not be an exclusion
criteria’
Davies et al Obesity and day surgery anesthesia Nov 2001
 ‘1992 RCS guidelines not adhered by 85%
units nation-wide’
Atkins et al Day sugery and BMI: results of national survey Feb 2002
Dr. H. Metwally
Distribution of Weight
 Mean weight:
Slice 3
23%
72.88 ± 3.5 kg
 Range: 47-124 kg
 < 50 kg (slice 1)- 6%
51-70 kg(slice 2) -58%
71-90 kg(slice 3) -23%
> 90 kg (slice 4) - 13%
Slice 4 Slice 1
6%
13%
Slice 1
Slice 2
Slice 2
58%
Slice 3
Slice 4
Dr. H. Metwally
Unplanned Admission
 Indicator of quality of the service provided
Raising the standard: The Royal College of Anaesthetisis
 Only 1 out of 83 ( 1.2%) patients in this
group ( TIVA) was admitted for severe
nausea and vomiting
 Overall rate of unplanned admissions 60/ 601 ( nearly 10%) in 2001
Dr. H. Metwally
Cost
 Cost analysis data not available for TIVA vs
conventional anaesthesia in the literature
 Should include costs saved by preventing
post-operative morbidity / unplanned
admission
 Costs £230 ($ 415) for single patient
experiencing severe PONV
Carroll et al J Clin Anesth1994
Dr. H. Metwally
Conclusions
 TIVA without muscle relaxants is a safe
and effective technique for day case
laparoscopic surgery
 Along with multi-modal analgesia and
antiemesis, TIVA reduces post-operative
morbidity and unplanned admission rate
Dr. H. Metwally
Thank You

Total Intravenous Anaesthesia ( TIVA) for Laparoscopic Day Surgery

Transcription

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