J. Blasl - Regional Anaesthesia

Laparoskopische Eingriffe + Regionalanästhesie:
Sinn oder Unsinn?
J. Blasl
November 2015
AIC 12.-14.11. 2015 Wien
„Von der Instabilität zur Stabilität“
Laparoskopische Eingriffe + Regionalanästhesie: Sinn oder Unsinn?
J. Blasl
Conflict of interest in relation to the above mentioned topic:
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I have NO conflict of interest
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Laparoskopische Eingriffe +
Regionalanästhesie: Sinn oder Unsinn?
-
Laparoskopiearten
Proceduren spez. Schmerz
Verfahrensempfehlungen
Fast Track
Nur RA ?
EK – Golden Standard
TAP
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Literatur
Technik
Alltag
Conclusio
Laparoskopische Eingriffe + Regionalanästhesie:
Herbst 2015:
SILS-Wedgeresektion Magen, LAGB, Gastric Banding, Sleeve-Gastrektomie, Pouch-Neuanlage, SILSFundoplicatio, Hiatusplastic, Hemihepatektomie, Pankreaslinksresektion, SILS-Milzexstirpation
Leberteilresektion, SILS-CHE, SILS –TVR, SILS-Rectopexie, SILS-Ileocoecalresektion ,Hemicolektomie,
AE, Sigmares.,TAMIS, SILS-IPOM, SILS-TAPP, Retroperit. Adrenalektomie, Bridenileus – diagnost. Lap,
Adhäsiolyse,, Narbenhernie-IPOM, Re.Lap bei Peritonitis, SILS-TEP - H.Ing, BPV mit sublay mesh,
Single incision laparoscopic surgery animation.
Madhoun N et al . Colorectal surgery Oct 2015
LOS more than 1d shorter for SILS , lower blood loss , decreased blood transfusion
requirement ,shorter time to flatus ,shorter hospital stay, smaller incision
Surgical Procedure-specific Pain
BJA 1997
Anesthesiology 2013
Surgical Procedure-specific Pain Intensity
high pain intensities were often ignored or not taken seriously, so that analgesic
administration was delayed and/or insufficient.
In laparoscopic surgeries with high postoperative pain scores, comparably low opioid
doses were used.
the administration of analgesics should be adjusted according to the individual patient’s
reported pain scores and desire for additional medication.
Epidural analgesia for laparoscopic …… might not be necessary in the context of fast-track program
Abdominal Wall Block ?
Laparoscopic colonic resection
Operative techniques: Laparoscopic colonic resection is recommended over open colon
surgery for reducing postoperative pain, if the conditions outlined above allow (Grade A)
Epidural analgesia: recommended in high-risk pulmonary patients (Grade D)
Wound infiltration/infusion: Pre-closure wound infiltration with LA (Grade B)
Laparoskopische Eingriffe – NUR Regionalanästhesie ?
.. routine anaesthesia of choice is feasible and safe. … can be recommended to be the anaesthesia technique of choice for
conducting laparoscopic cholecystectomy in hospital setups in developing countries where cost factor is a major factor.
Laparoscopic cholecystectomy under spinal anaesthesia: A prospective, randomised study.Tiwari S et lal. J Minim
Access Surg. 2013 Apr. Uttar Pradesh India 224
…. with proper selection of patients and limiting IAP to 10-12 mmHg, … can be safely performed with
spinal anaesthesia with some supplementation
Regional anaesthetic technique for laparoscopic appendcectomy 2014 Sep Ibadan Nigeria 8
performed safely under epidural anaesthesia …. severe COPD. 1998 Aug
Laparoscopic cholecystectomy under epidural anesthesia in patients with chronic respiratory
disease. Pursnani KG et al Lancashire GB 6
….the sole anaesthesia technique is feasible, safe and cost effective for elective CHE
Laparoscopic Cholecystectomy Under Spinal Anaesthesia vs. General Anaesthesia: A Prospective Randomised Study.
2014 Aug Bangalore, India 25/25
…. with Morphine-mixed hyperbaric Bupivacaine is adequate and safe for elective LC in otherwise healthy patients and
minimises postoperative pain and opioid use. Success and safety of this technique, however, necessitates knowledgeable
patient, gentle surgical procedure, and co-operation among patient and members of the perioperative care team. Spinal
anaesthesia for laparoscopic cholecystectomy: a feasibility and safety study. Gautam B 2009 Kathmandu 12
Laparoskopische Eingriffe – NUR Regionalanästhesie ?
gaslose
Lift-Laparoskopie
Spinale/EK
Bauchspiegelung ohne Vollnarkose hat enorme Vorteile für Patienten
Bewusstes „Teilhaben“
im Operationssaal
Während OP kommunizieren
Operateur und Anästhesist
mit Patientin
http://www.laparoskopie-ohne-vollnarkose.de/
reasons for the decline
invasive
costly + labour-intensive
advances in surgical techniques
prophylactic anticoagulant regimens
severe neurologic complications
evidence of decreased morbidity ?
evidence of postop.mortality ?
A nationwide analysis of the use and outcomes of perioperative epidural analgesia in
patients undergoing hepatic and pancreatic surgery. Amini N et al. AmJSurg 2015 Sept
2002 -2012: 3961 (7,4%) The use of EA among minimally invasive procedures increased from 3.8% in
2000 to 9.1% in 2012. EA: reduction specific pulmonary-related complications, sepsis, in-hospital mortality
2002 -2010 : Analgesia superiority over conventional analgesia, did not affect pneumonia, respiratory failure,
urinary retention, anastomotic leak, and postoperative ileus.
Epidural analgesia 2.14% 4102 (191576 )
longer hospital stay by 0.60 day + higher hospital charges by $3732.71 +higher rate of urinary tract infection,
epidural analgesia appears to be safe.
TAP
Transversus abdominis plane block for postoperative analgesia after
laparoscopic surgery Int J Clin Exp Med 2014 14
Daryl I. Smith et al . Rochester
significant reduction in analgesic consumption during 24 h;
effectively increase incidence of postoperative nausea and
vomiting adverse effect needs more clinical trials to confirm due to
the small number of participants - significant heterogeneity
good evidence: a reduction in pain scores and analgesic requirement, no significant difference when compared to
local anaesthetic infiltration of trocar insertion sites.
Does a transversus abdominis plane (TAP) local anaesthetic block improve pain control in patients
undergoing laparoscopic cholecystectomy? A best evidence topic. UK 2013 Jun
TAP
.. improved immediate short-term opioid use and pain outcomes. Pain improvement was durable throughout the
hospital stay. blocks did not translate into less overall narcotic use, shorter length of stay, or lower readmission rates.
The effect of transversus abdominis plane blocks on postoperative pain in laparoscopic colorectal surgery
a prospective, randomized, double-blind trial. Keller DS et al. Dis Colon Rectum 2014 Nov 41/38
Cleveland, Ohio.
bilateral TAP block with 0.5% bupivacaine reduces pain intensity and fentanyl request and prolongs time to the first
analgesic request. Adding sufentanil to the block solution reduced neither pain intensity nor fentanyl further
consumption.
Efficacy of transverse abdominis plane block in reduction of postoperation pain in laparoscopic
cholecystectomy Salimina A et al. 2015 Aug 14. Teheran 18/18/18
TAP
.. combined with paracetamol and Nonsteroidal anti-inflammatory drugs (NSAID) treatment, had no effect on morphine
consumption, VAS pain scores, or frequency of nausea and vomiting after robot-assisted laparoscopic hysterectomy compared
with paracetamol and NSAID alone. (ropivacaine 0.5%, 20 ml on each side)
Transversus abdominis plane TAP block after robot-assisted laparoscopic hysterectomy a randomised clinical
trial. Torup H et al. Denmark 2015 Mai 31/30
Compared with local anesthetic infiltration, bilateral TAP blocks decreased the cumulative morphine use at 24 h and 48 h
postoperatively
Effect of local wound infiltration and transversus abdominis plane block on morphine use after laparoscopic
colectomy: a nonrandomized, single-blind prospective study. Park JS et al 2015 May Daegu, Korea.30/29
ultrasound guidance; no difference to analgesic consumption, no difference secondary outcomes of daily VAS, respiratory
outcome, time to return of gut function, length of hospital stay, postoperative complications, and patient satisfaction. TAP
blockade appears to be a safe intervention but confers no specific advantage following laparoscopic colorectal surgery.
Transversus abdominis plane blockade in laparoscopic colorectal surgery a double-blind randomized clinical
trial Int J Colorectal Dis. 2015 Sep 74-68
TAP
Ziel : antero-lateral rami of the thoracoabdominal nerves (Th6-Th12).
– lateral classical TAP block (above the iliac crest and below
the thoracic cage) (El-Dawlatly et al. and Shibata et al.)
bilat. - welltrained approximately 5-6 min
Idea: dermatomes Th6-Th12 antero-medial muscles abdominal wall +
underlying parietal peritoneum
USG oblique subcostal transversus abdominis plane
blockade (Hebbard 2010):
lower (Th10-Th 12) + upper (Th6-Th9) abdominal wall
Optimum: entire abdominal wall (TH6-L1): classical TAP + intercostal
TAP (epigastric area)
posterior TAP block
benefits : reduced postoperative opioid requirements lower pain
scores or a reduction in opioid-related side effects, higher patient
satisfaction versus surgical procedures, anaesthetic doses,
techniques, and timing (pre- or post-incisional)
Quadratus lumborum (QL) block
visualize the thoracolumbar fascia
at the lateral edge of the QL
distribution area from Th6 to L1 dermatomes
pattern of a shamrock with three leaves
Truncal blocks
2012
2012
entire abdominal wall pain-free all the antero-lateral rami of the thoracoabdominal nerves (Th6-Th12).
Intercostal TAP plexus (Th6-Th9) + classical TAP plexus (Th10-Th12)
Wann ist Arbeit sinnvoll?
Which Drug is Better For Post-op Pain Control?
TAP Blokade
Tageschirurgie CHE
Chirurgie - Laparatomie
Rectus sheath
The central portion of the anterior abdominal wall is innervated by the ventral branches of the thoracolumbar
nerves (Th6-L1) Between the belly of the rectus abdominis muscle and the posterior rectus sheath
Which Drug is Better For Post-op Pain Control?
12 Monate
TAP 453
TAP Kath 59
Rectus sheath 26
2011/6 -
161
2012/6 -
132
2013/6 -
118
2014/6 -
49
2015/6 -
67
PACU
50 - 60% Reduction of morphine
Wann ist Arbeit sinnvoll?
Bedeutsamkeit der Tätigkeit
Wissen um das „Warum“
Einbindung in übergeordneten Zusammenhang
Kohärenz von beruflicher Tätigkeit und persönlichen Interessen, Werten, Fähigkeiten