and Günter Lippert1
(1)
Department of Anaesthesiology, St. Antonius Hospital, Gronau, Germany
Abstract
Time and again the use of innovative surgical techniques confronts anaesthetists with the task of selecting the most suitable type of anaesthesia for the respective procedure, adapting it to the new requirements and ensuring dependable perioperative patient care by means of a patient-oriented, continuous improvement process. The aim of this paper is give a presentation – from practitioners for practitioners – of the standardised anaesthetic procedure that was developed at our hospital and has proven successful in over 1,500 operations, as well as its special features in connection with use of the Da Vinci.
2.1 Introduction
Time and again the use of innovative surgical techniques confronts anaesthetists with the task of selecting the most suitable type of anaesthesia for the respective procedure, adapting it to the new requirements and ensuring dependable perioperative patient care by means of a patient-oriented, continuous improvement process. The aim of this chapter is to give a presentation – from practitioners for practitioners – of the standardised anaesthetic procedure that was developed at our hospital and has proven successful in over 1,500 operations, as well as its special features in connection with use of the Da Vinci.
2.2 Before the Operation
As before every operation, a premedication talk is held with the aim of exchanging information. The anaesthetist gets an impression of the current state of health of the patient during this talk, and on the basis of the medical history and the physical examination. At the same time, he informs the patient about the planned anaesthetic procedure in the form of balanced general anaesthesia. An ECG and a laboratory check are performed as standard for further diagnosis. Since our experience shows that a need for intraoperative blood transfusion is not to be expected, there is no need for corresponding preparatory measures. If a particular cardiac risk is suspected as a result of the premedication talk, further examinations are performed by the in-house cardiologist. The operation should be deferred if this examination reveals therapeutic consequences that could contribute to reducing the cardiac risk. In the event of manifest organ failures that can no longer be improved and substantially impair the patient’s stress tolerance (>ASA III), consideration should be given to performing a different therapeutic procedure (e.g. brachytherapy or EBRT). Similarly, obesity that is of a truncal nature, and thus cannot be determined solely on the basis of the BMI, can make the procedure impossible: partly for ventilation-related, i.e. anaesthesiological reasons and partly for positioning and instrument-related, i.e. surgical, reasons.
For preoperative anxiolysis and sedation, the patient is routinely given a benzodiazepine (dipotassium clorazepate [Tranxilium®] 20–30 mg p.o.) on the previous evening and on the day of the operation. The perioperative pain concept commences preoperatively with a COX-2 inhibitor (etoricoxib [Arcoxia®] 1–1.5 mg/kg BW p.o.). Preoperative prophylaxis of postoperative nausea and vomiting (PONV) is performed in corresponding cases by means of the H1 receptor antagonist dimenhydrinate 50 mg p.o. and is intraoperatively supplemented by dexamethasone [Fortecortin®] 4 mg i.v. in individual cases.
2.3 Operation
Preparation of Anaesthesia
On the day of the operation, the patient is greeted by the anaesthesia nurse and the anaesthetist, the check of his identity and his findings being documented in a special time-out record. After positioning the patient on the operating table equipped with a vacuum mattress, further preparation is performed in the ante-room of the operating theatre.
In addition to the 3-lead ECG, and owing to the apposition of both arms and the 30° Trendelenburg position, the standard provides for a “bilateral procedure”: establishment of peripheral venous accesses (17G/18G) on the back of both hands or on both forearms, application of pulse oximetry sensors to the middle finger of both hands, wrapping of both arms in cotton wool to protect against postural damage application of sphygmomanometer cuffs to both upper arms. The two crystalloid infusions (à 500 ml Sterofundin®) connected to the peripheral venous accesses are stopped. Both the risk of a vesicourethral anastomotic leak and the possibility of intraoperative development of cerebral or pulmonary oedema owing to the extreme head-down position are minimised by a restrictive fluid supply.
Only in cases of cardiac risk is the standard extended to include a 5-lead ECG for ST-segment analysis and invasive blood pressure measurement (left-side A. radialis), as well as an external pacemaker and central venous catheter, where appropriate.
Every patient receives a cephalosporin [Cefuroxim® 1.5 g] i.v. as a single-shot antibiotic, alternatively being given ciprofloxacin [Ciprobay® 500 mg], for example, in case of intolerance.
Induction of Anaesthesia
Following connection of the monitoring equipment, anaesthesia is induced in the operating theatre. Norepinephrine is administered by means of a Perfusor syringe pump [Arterenol® 0.02 mg/ml at 0.1–25 ml/h] to stabilise the haemodynamics. As standard, induction is performed i.v. with Sufenta® 15 μg, propofol 2–2.5 mg/kg BW and rocuronium 0.5 mg/kg BW. Oral intubation is followed by minimal flow ventilation, sevoflurane or desflurane being added. A stomach tube is inserted orally for the duration of the operation to drain the gastric juice. Special protective glasses that fit tightly on all sides are put on to additionally protect the patient’s eyes against the possibility of position-induced penetration of fluids, such as blood or gastric juice, during the operation, and simultaneously to prevent drying of the eyes in the event of incomplete lid closure (see Fig. 2.1). A gauze compress inserted into the mouth helps avoid damage to the lips and tongue as a result of exposure to uncontrolled pressure. A nasal temperature sensor permits monitoring of the body temperature, external heat being supplied by means of a thermal blanket. Only then does the team position the patient on the operating table: after bending the legs to the side, both arms are positioned closely against the body and fixed by evacuating the appropriately adjusted vacuum mattress, the head also being fixed on the pillow in this way. The patency of the two infusion systems is subsequently checked once more, after which the systems are stopped again (see Fig. 2.2 and 2.3).
