Noninvasive Positive Pressure

Ventilation during Combined

Spinal Epidural Anaesthesia
For Laparoscopic
Cholecystectomy in COPD Pt
– A new approach

Dr Prashant S
Agarwal
Dr Ashok Jadon
TATA Motors Hospital
 Problem
 Lap – choice of approach for
cholecystectomy
 Post op Ventilation - Major risk for COPD
Patients

Regional Anaesthesia
diaphragmatic irritation - requires –
Sedation
GA -- ?
respiratory compromise
 Solution
 Regional + NPPV

(BiPAP)

 FRC
 Auto PEEP
 Splinting of Airway
 V/Q mismatch
 Prevents atelectasis
 work of breathing
 Augments/Supports
Ventilation
 AIM
To see the feasibility
and complications of
BiPAP in severe
COPD patients
undergoing
Laparoscopic
Cholecystectomy
under Combined
Spinal Epidural
Anaesthesia
 Patients & Methods
 Approval (TATA Motors Hosp. ethical committee)
 June 2008 till now
 6 pt.s with COPD for Lap Chole
 H/O Bronchodilator therapy, Dyspnea (grade II/III),
Repeated Hosp. admission
 PAC, Informed Consent
 Admitted day before Surgery
 Chest physio, Nebulisation & Medication
 Premed –
 Alprazolam 0.5 mg, Rantidine 150 mg, Metoclopramide
10 mg
 Monitoring – PR, SpO2, NIBP, ECG & Temp
 IV access
 Pre-induction ABG
 Anaesthetic Management
 CSEA –  BiPAP –
 Sitting  Face Mask
 T9-10 Para median  PE – 4 cm of H2O
 Needle through needle  PI – 16 cm of H2O
 Epi Cath 3-4 cm
cephalad
 Sedation – Propofol 25 mcg/kg/min (Titrated)
 Intra-op ABG
 BP – 20% of baseline [ ephedrine(5 mg) ]
 Bradycardia < 60/min [ atropine(0.6 mg) ]
 Propofol stopped during skin closure
 BiPAP withdrawn
 Post-op O2 for 24 hrs, analgesia – Epi Infusion
 DATA
 Demographic –
 Sex (M:F) – 1:5
 Age (mean) – 69 yrs (52 - 84)
 Weight (kg) – 51.6 kg (45 - 63)
 Observations –
 SpO2 – maintained >92%
 Ephedrine (5mg) – 2:0:1:3:1:2 (mean – 7.5mg)
 Atropine (0.6mg) – 0:0:1:1:0:1 (mean – 0.3mg)
 IVF (mean) – 1835 ml(1500-2800)
 Duration of Surgery (mean) – 182.5 min (140-230)
 Complications –
 Gastric distention – 1
 Resp Rate < 10/min – 0
 Conversion to GA – 0
 Aspiration – 0
 PONV – 0
 Post op Resp. complications – 0
 ABG Analysis
PaO2 PCO2 pH Bicarb
DATA
Pre Intra Post Pre Intra Post Pre Intra Post Pre Intra Post
Induc op Op Induc op Op Induc op Op Induc op Op

Pt 1 92.1 107 93.4 55 53.6 53.8 7.34 7.38 7.38 32 31.6 31.3
Pt 2 82.5 87.5 81.3 51.5 49.3 51 7.37 7.39 7.36 30.9 32.1 32.6
Pt 3 99.4 103.4 102 46.3 41.8 40.2 7.39 7.39 7.4 35.7 33.9 35.1
Pt 4 76.9 86.1 83.6 61.4 56.2 58.1 7.32 7.34 7.34 29.8 30.3 29.7
Pt 5 89.3 99.3 90.7 53.9 51.1 53.6 7.39 7.4 7.38 33.5 33.2 32.9
Pt 6 85.7 106 90.2 60.2 59.5 59.9 7.33 7.34 7.34 28 29.5 30
Mean 85.8 98.2 90.3 54.73 51.9 53.6 7.35 7.36 7.36 31.5 31.7 31.9
9 5
SD + 11 9.24 7.67 5.59 5.16 6.35 .026 .026 .025 2.32 2.31 2.08

P* >0.05 >0.05 >0.05 >0.05

Value

* AcaStat 5.3.1
 Disadvantages
 Gastric distension
 Eye injury
 Skin Erosion
 Claustrophobia
 Aspiration
 Pneumothorax
 Sinusitis
 Results
 6 pts of severe COPD for lap chole
 Managed with CSEA + BiPAP
 Intra op Vitals stable
 PaO2 & PCO2 Maintained
 1 case of Gastric Distention (Ryle’s
Tube)
 No case converted to GA
 No post op complications
 Discussion / Review
Literature
 Lap Chole Regional Anaesthesia
 A. A. J. van Zundert et al. Laparoscopic cholecystectomy
under segmental thoracic spinal anaesthesia. BJA 2007
May;98; 682-686(5).
 K. G. Pursnani et al. Laparoscopic cholecystectomy under
epidural anesthesia in patients with chronic respiratory
disease. Surg Endosc 1998; 12: 1082–1084.

 BiPAP Regional Anaesthesia

 Warren J et al. Ventilatory support using Bilevel positive
airway pressure during neuraxial blockade in a patient with
severe respiratory compromise. Anesth Analg 2006;
102:910–11.
 Iwama H et al. Application of nasal bi-level positive airway
pressure to respiratory support during combined epidural-
propofol anesthesia. J Clin Anesth 2002; 14:24–33.
 Conclusion

 BiPAP reduces the respiratory

embarrassment created by
pneumoperitoneum and anaesthesia.
 BiPAP can be used intraoperatively in
combination with neuraxial block for
the management of severe COPD pts
during Laparoscopic
Cholecystectomy.
 Bibliography

 Yuksek YN, Akat AZ, et al. Laparoscopic cholecystectomy under

spinal anesthesia. Am J Surg 2008 Apr; 195(4): 533-6.
 A. A. J. van Zundert, G.Stultiens, et al. Laparoscopic
cholecystectomy under segmental thoracic spinal anaesthesia. BJA
2007 May; 98 : 682-686(5)
 K. G. Pursnani et al. Laparoscopic cholecystectomy under epidural
anesthesia in patients with chronic respiratory disease. Surg
Endosc (1998); 12 : 1082–1084.
 Warren J, Sharma SK. Ventilatory support using Bilevel positive
airway pressure during neuraxial blockade in a patient with severe
respiratory compromise. Anesth Analg 2006;102:910–11.
 Ferrandière M et al. Non-invasive ventilation corrects alveolar
hypoventilation during spinal anesthesia. Canadian Journal of
Anesthesia 2006; 53:404-408.
 Iwama H. Application of nasal bi-level positive airway pressure to
respiratory support during combined epidural-propofol anesthesia.
J Clin Anesth 2002; 14 : 24–33.