Anaesthesia for Lap Chole

 

 

Assuming the patient to be a healthy 55yo woman weighing 75 kg whose pre anaesthetic assessment is unremarkable. Establish IV access and attach monitoring.

Give cephalothin 1gm IV. (Better to have any anaphylactic reaction prior to induction). Give 100 mcg fentanyl. Pre-oxygenate patient until ET O2 over 80%  if potential airway difficulties, otherwise 3 – 4 deep breaths.

Give propofol 150mg (containing  lignocaine 20mg) followed immediately by rocuronium 35 mg. Begin gently ventilating with bag and mask. Observe monitor to ensure adequate oxygenation and ventilation. Add in sevoflurane 4%. Continue ventilating while monitoring HR, BP, O2 saturation, CO2 level and trace and ET sevofurane level.

After about 2 minutes perform laryngoscopy. If there is a good view of the larynx then pass an oro-gastric tube followed by an endotracheal tube. Connect the circuit ventilator and then check monitors and ventilator pressure. Secure ETT and orogastric tube, tape eyes, secure arms safely and comfortably.

Position operating table.

The following text was added after receiving Comments 1 and 2 (thanks, the feedback is much appreciated):

(The surgeon requests the NG tube as gas in the stomach can make surgical access difficult. It is a lot easier to gently position an NG tube before intubation than part way through the operation. Should I argue the point with him?  Have you met this guy?.......!!!)

Give O2/Air with FiO2 60% and sevoflurane to achieve ET sevo around 2.1%. Add morphine titrating up to 10 mg depending on HR and BP. Even so sometimes I find patients tachycardic and hypertensive when pneumoperitoneum established despite morphine and 1 MAC sevoflurane. For this I use metoprolol 1 mg PRN up to 3 mg.

As well I give parecoxib 40 mg for post-op analgesia and dexamethazone 8 mg for PONV prophylaxis (plus droperidol 0.5 mg if high risk of PONV).

At the end of the procedure I don't reverse the muscle relaxant if the patient is demonstrating good breathing and coughing. I remove the NG tube under suction before extubation.

 

Comment 1 

For lap chole - this is old fashioned.....
1/ You don't need an ETT. A proseal etc is fine.
2/ If you are gentle with pre airway stuff - and we all are, aren't we? you don't need a NG tube. I used to do this and only do it if the surgeon asks for it which has only happened once since, and he was wrong.

 

Comment 2

"I feel your "how to anaesthetise for lap chole" is very much incomplete. I assume you are using no nitrous but are you using air, what do you do with the oro gastric tube if you don't have a good view of the larynx, why risk trauma from orogastric tube when with gentle bag mask ventilation it might not be needed at all? When do you remove the orogastric tube, what reversal do you use if any, etc etc etc"