British Journal of Anaesthesia 113 (1): 186–98 (2014)
CORRESPONDENCE Laparoscopic surgery in a morbidly obese, high-risk cardiac patient: the benefits of deep neuromuscular block and sugammadex Editor—Intraperitoneal insufflation of carbon dioxide for laparoscopic surgery can produce cardiac depression that is poorly tolerated in high-risk cardiac patients with a low ejection fraction (EF).1 2 Consequently, carboperitoneum is not advocated for morbidly obese patients with severe cardiac dysfunction.1 We describe our experience with a 48-yr-old man undergoing laparoscopic sleeve gastrectomy and abdominoplasty for morbid obesity. He weighed 127 kg, and his BMI was 40 kg m22. He had metabolic syndrome and end-stage idiopathic cardiomyopathy. His medications included sotalol, digoxin, enalapril, furosemide, spironolactone, lansoprazole, and enoxaparin. The surgery was performed to allow him to be eligible for a heart transplant. A preoperative ECG displayed atrial fibrillation with a ventricular rate of 78 beats min21, and a transthoracic echocardiogram showed global hypokinesis with a 17% left ventricular EF, plus mild mitral and tricuspid regurgitation. Cardiac catheterization revealed pulmonary hypertension (55/25 mm Hg) and a low cardiac index (1.6 litre min21 m22). Upon entering the operating theatre, the patient underwent insertion of a peripheral venous line and a radial arterial line. Moderate reverse Trendelenburg position was gradually instituted before anaesthesia induction. It was well tolerated by the patient. After 3 min preoxygenation with 100% oxygen, anaesthesia was induced with ketamine 50 mg, fentanyl 200 mg, thiopental 75 mg, and rocuronium 1 mg kg21 [based on ideal body weight (IBW)]. Tracheal intubation was easily performed. After induction, the arterial pressure decreased to 75/35 mm Hg. This was treated with an epinephrine infusion at 0.15 mg kg21 min21, which restored the arterial pressure to baseline (112/68 mm Hg). Epinephrine was continued at this dose throughout surgery. The patient’s lungs were ventilated with a 35/65 oxygen/air mixture using pressure-controlled ventilation with a 1:1 inspiratory:expiratory ratio, peak inspiratory pressure adjusted to maintain the expiratory tidal volume at 10 ml kg21 IBW, and a respiratory rate adjusted to maintain the PaCO2 at 5 kPa (12 –14 bpm). A central venous pressure catheter and transoesophageal echocardiographic probe (iE33, Philips Medical Systems, Andover, MA, USA) were inserted to monitor cardiac filling pressures, left ventricular volume, and EF. Anaesthesia was maintained with desflurane (end-tidal concentration 5.3%) and remifentanil 0.05 –0.15 mg kg21 min21 to ensure a bispectral index value of 40. Neuromuscular monitoring (TOF-Watch SX, Organon Teknik, Ireland) started before rocuronium administration and was continued throughout surgery until the train-of-four (TOF) ratio returned to ≥1.0. When the post-tetanic count (PTC) returned to 1 after the initial dose of rocuronium, a continuous rocuronium infusion at
0.015 –0.025 mg kg21 min21 (IBW) was begun to maintain deep (1–5 PTCs) neuromuscular block (NMB) during the laparoscopic procedure. Laparoscopic surgery was begun after creating a carboperitoneum. The intra-abdominal pressure (IAP) was maintained at 1–1.3 kPa, which provided an adequate surgical view. Cardiovascular parameters remained within 10% of baseline throughout the 90 min laparoscopic sleeve gastrectomy (Table 1) and subsequent abdominoplasty. At the conclusion of surgery, remifentanil was discontinued, and ondansetron 4 mg, tramadol 50 mg, and ketoprofen 100 mg were administered for postoperative nausea and vomiting (PONV) and pain prophylaxis. Sugammadex 4 mg kg21 was administered to reverse the deep rocuronium-induced NMB. Complete NMB reversal (from 4 PTCs to a TOF ratio of 1.08) was achieved in 100 s. Desflurane was then discontinued, the patient awakened, and the tracheal tube removed 8 min later. The patient had no pain, PONV, or signs of residual NMB in the post-anaesthesia care unit (PACU). The epinephrine infusion was discontinued 30 min post-extubation. After observation for 2 days in the PACU, the patient was discharged to the medical ward. Laparoscopic surgery represents a particular challenge for clinicians of obese, high-risk cardiac patients.1 2 Carboperitoneum produces an acute increase in IAP (generally 1.6–2.1 kPa)3 and pushes the diaphragm upwards, thereby decreasing pulmonary compliance and increasing peak airway pressures.3 Mean arterial pressure and systemic and pulmonary vascular resistances are increased and, at least during the early phase of carboperitoneum, the stroke volume and cardiac output are reduced.3 4 In a transoesophageal echocardiographic study, carboperitoneum (2 kPa of pressure), with head-up tilt of 208, decreased cardiac index by 11% and stroke volume index by 22%, while increased both heart rate and mean arterial pressure by 14% and 19%, respectively.4 Carboperitoneum affects diastolic function by delaying deceleration time and impairing isovolumetric relaxation.5 It also predisposes to cardiac arrhythmias.3 Low-pressure carboperitoneum minimizes adverse haemodynamic effects6 but may not ensure optimal surgical conditions, especially in the presence of inadequate NMB.7 8 Deep NMB promotes a low-pressure (,1.6 kPa) peritoneum while providing adequate surgical access and visualization.7 8 It minimizes cardiac dysfunction associated with high IAP and reduces postoperative pain intensity, incidence of shoulder pain, and analgesic consumption, compared with moderate NMB.3 7 8 However, deep rocuronium-induced NMB requires sugammadex for safe, quick, and effective reversal at the end of surgery in morbidly obese patients with cardiovascular disease.7 – 10 In conclusion, deep NMB should be considered in all obese, high-risk cardiac patients undergoing laparoscopic surgery. Rocuronium plus sugammadex is the ideal combination for this purpose: it produces profound NMB during surgery
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Table 1 Cardiovascular parameters during laparoscopic sleeve gastrectomy in a morbidly obese patient with end-stage idiopathic cardiomyopathy. TOE images, transoesophageal echocardiographic images (long-axis view); LV, left ventricular Before carboperitoneum
During carboperitoneum
After carboperitoneum
Systolic arterial pressure
110
120
115
Mean arterial pressure
84
88
83
Diastolic arterial pressure
70
72
68
Heart rate
65
67
64
Central venous pressure
4
6
2
Cardiovascular parameters
TOE images
TOE measurements Diastolic LV length (cm)
10.4
10.3
10.6
LV area (cm2)
53.3
52.0
54.8
LV volume (ml)
208
205
216
LV length (cm)
9.29
9.27
9.64
LV area (cm2)
45.1
44.8
45.9
LV volume (ml)
175
172
182
Ejection fraction (%)
16
16
16
0.15
0.15
0.15
Systolic
Cardiovascular drugs Epinephrine (mg kg21 min21)
plus a safe, rapid recovery from deep rocuronium-induced NMB after surgery.
Declaration of interest M.C. has received payments for lectures from Merck Sharp & Dohme (MSD), Italy. M. Carron* M. Gasparetto V. Vindigni M. Foletto Padova, Italy * E-mail:
[email protected] 1 Jones PE, Sayson SC, Koehler DC. Laparoscopic cholecystectomy in a cardiac transplant candidate with an ejection fraction of less than 15%. JSLS 1998; 2: 89 –92 2 Nguyen NT, Wolfe BM. The physiologic effects of pneumoperitoneum in the morbidly obese. Ann Surg 2005; 241: 219– 26 3 Gurusamy KS, Samraj K, Davidson BR. Low pressure versus standard pressure pneumoperitoneum in laparoscopic cholecystectomy. Cochrane Database Syst Rev 2009; 15: CD006930
4 Dorsay DA, Greene FL, Baysinger CL. Hemodynamic changes during laparoscopic cholecystectomy monitored with transesophageal echocardiography. Surg Endosc 1995; 9: 128–33 5 Russo A, Marana E, Viviani D, et al. Diastolic function: the influence of pneumoperitoneum and Trendelenburg positioning during laparoscopic hysterectomy. Eur J Anaesthesiol 2009; 26: 923– 7 6 Dexter SP, Vucevic M, Gibson J, McMahon MJ. Hemodynamic consequences of high- and low-pressure capnoperitoneum during laparoscopic cholecystectomy. Surg Endosc 1999; 13: 376– 81 7 Geldner G, Niskanen M, Laurila P, et al. A randomised controlled trial comparing sugammadex and neostigmine at different depths of neuromuscular blockade in patients undergoing laparoscopic surgery. Anaesthesia 2012; 67: 991–8 8 Martini CH, Boon M, Bevers RF, Aarts LP, Dahan A. Evaluation of surgical conditions during laparoscopic surgery in patients with moderate vs deep neuromuscular block. Br J Anaesth 2014; 112: 498– 505 9 Carron M, Veronese S, Foletto M, Ori C. Sugammadex allows fasttrack bariatric surgery. Obes Surg 2013; 23: 1558– 63 10 Dahl V, Pendeville PE, Hollmann MW, Heier T, Abels EA, Blobner M. Safety and efficacy of sugammadex for the reversal of rocuronium-induced neuromuscular blockade in cardiac patients undergoing noncardiac surgery. Eur J Anaesthesiol 2009; 26: 874– 84
doi:10.1093/bja/aeu211
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