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Surgical procedures have come a long way in recent years, with minimally invasive techniques like laparoscopy gaining popularity due to their numerous advantages. However, it's important to recognize that not all patients are suitable candidates for laparoscopic surgery. Individuals with underlying medical conditions, such as Chronic Obstructive Pulmonary Disease (COPD) and cardiac diseases, may face significant challenges and risks when undergoing laparoscopy. This article explores why laparoscopy may not be the ideal choice for COPD and cardiac disease patients and what alternative approaches may be more suitable.
Understanding Laparoscopy
Laparoscopy, often referred to as minimally invasive surgery, involves making small incisions and using specialized instruments and a camera to perform surgical procedures. This approach offers several benefits, including reduced post-operative pain, shorter hospital stays, and faster recovery times. However, its suitability depends on the patient's overall health and specific medical conditions.
COPD: A Respiratory Challenge
COPD is a chronic respiratory disease characterized by airflow obstruction and difficulties in breathing. Patients with COPD often have reduced lung function and may rely on oxygen therapy or inhalers to manage their condition. Laparoscopic surgery, which requires the abdomen to be inflated with carbon dioxide gas to create a working space, can pose significant challenges for COPD patients.
1. *Impaired Respiratory Function:* The insufflation of carbon dioxide during laparoscopy can put added pressure on the patient's respiratory system. This can lead to reduced oxygen levels and increased carbon dioxide levels in the blood, which is particularly problematic for COPD patients who already have compromised lung function.
2. *Increased Risk of Respiratory Complications:* COPD patients undergoing laparoscopic surgery are at a higher risk of developing respiratory complications such as atelectasis (collapsed lung), pneumonia, and exacerbations of their underlying COPD.
Cardiac Disease: A Concern for the Heart
Cardiac diseases encompass a range of conditions affecting the heart, including coronary artery disease, heart failure, and arrhythmias. Patients with cardiac diseases often have impaired heart function, which can be exacerbated during laparoscopic surgery.
Surgical procedures have come a long way in recent years, with minimally invasive techniques like laparoscopy gaining popularity due to their numerous advantages. However, it's important to recognize that not all patients are suitable candidates for laparoscopic surgery. Individuals with underlying medical conditions, such as Chronic Obstructive Pulmonary Disease (COPD) and cardiac diseases, may face significant challenges and risks when undergoing laparoscopy. This article explores why laparoscopy may not be the ideal choice for COPD and cardiac disease patients and what alternative approaches may be more suitable.
Understanding Laparoscopy
Laparoscopy, often referred to as minimally invasive surgery, involves making small incisions and using specialized instruments and a camera to perform surgical procedures. This approach offers several benefits, including reduced post-operative pain, shorter hospital stays, and faster recovery times. However, its suitability depends on the patient's overall health and specific medical conditions.
COPD: A Respiratory Challenge
COPD is a chronic respiratory disease characterized by airflow obstruction and difficulties in breathing. Patients with COPD often have reduced lung function and may rely on oxygen therapy or inhalers to manage their condition. Laparoscopic surgery, which requires the abdomen to be inflated with carbon dioxide gas to create a working space, can pose significant challenges for COPD patients.
1. *Impaired Respiratory Function:* The insufflation of carbon dioxide during laparoscopy can put added pressure on the patient's respiratory system. This can lead to reduced oxygen levels and increased carbon dioxide levels in the blood, which is particularly problematic for COPD patients who already have compromised lung function.
2. *Increased Risk of Respiratory Complications:* COPD patients undergoing laparoscopic surgery are at a higher risk of developing respiratory complications such as atelectasis (collapsed lung), pneumonia, and exacerbations of their underlying COPD.
Cardiac Disease: A Concern for the Heart
Cardiac diseases encompass a range of conditions affecting the heart, including coronary artery disease, heart failure, and arrhythmias. Patients with cardiac diseases often have impaired heart function, which can be exacerbated during laparoscopic surgery.
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LearningTranscript
00:00Contraindications of laparoscopic surgery is very important to remember.
00:05So contraindication of laparoscopic surgery, one of the most important contraindication
00:10of laparoscopic surgery is severe COPD and cardiac disease.
00:16Any patient who has severe chronic obstructive pulmonary disease and cardiac disease, you
00:22are not allowed to do laparoscopy, you will be in trouble.
00:29Any patient who has severe COPD and cardiac disease, you should not perform laparoscopy.
00:36Question is why, what is wrong in laparoscopy to do with problem is not laparoscopy problem
00:42is pneumoperitoneum and these are the four major risk of pneumoperitoneum.
00:52These are four major risk of pneumoperitoneum due to that we should avoid doing laparoscopy
00:58in a patient who has severe COPD and cardiac disease.
01:03First is decreased venous return and cardiac output.
01:07In university, they did one study.
01:12In the large animal, they put the different gases in the pneumoperitoneum in John Hopkins.
01:22They watch that what happens post pneumoperitoneum in the first group of animal, they use 6 millimeter
01:30of mercury pressure by a plastic wearis needle in a 70 kg of chimpanzee and they observe it
01:41for 24 hours.
01:43What is happening to animal and there was no change, animal was ok, eating, drinking, sleeping,
01:53all the parameters, all the vitals were fine.
01:58Because our venakava pressure is 6 and if you put only 6 millimeter of mercury pressure, venakava
02:06cannot be compressed, diaphragm cannot be compressed.
02:11So, any animal of the large animal of human size can tolerate it.
02:20Second group of the animal, they use 12 millimeter of mercury pressure and again for 24 hours.
02:28In 12 millimeter of mercury pressure, there was 20 percent reduction in the cardiac output CO,
02:3620 percent reduction because venakava pressure is 6 and your pressure is 12.
02:42So CO2 is not only lifting the abdominal wall, it is compressing the venakava also.
02:48So venous return decreases.
02:50Now, third group of the animal, but still the animal was vitals were normal, pulse BP respiration
02:58normal, but animal was not willing to eat, not willing to drink, lying very sick, but survived
03:0524 hour survived.
03:07Third group of animal, they use 18 millimeter of mercury and for again 24 hour and within 6
03:19hour, it was unconscious.
03:25It become unconscious and in the fourth group of animal, they use 24.
03:33So, 66 millimeter was increased and here within 3 hour, there was death.
03:45So, the influence of this study is that ideal pressure should be 12 or 15.
03:53If just you go from 12 to 18, pressure is increased only 1.5 times, but venous return decrease approximately
04:0240 percent here, 40 percent reduction was there in the venous return.
04:09So, if patient is already cardiac compromise, hidden ischemia, ASD, VASD, previous any cardiac
04:22bypass surgery or multiple stent was applied.
04:27Then this 40 percent reduction in the cardiac output will precipitate the ischemia and he can
04:34get intraoperative heart attack or may be the infarction or death.
04:39So, that is why any patient who come in a laparoscopy with the previous cardiac history, you should
04:46send for a stress echo or dabutamine echo, normal echo does not have any value, stress echo if
04:54he can run, if he is obese or physically not possible then dabutamine echo has to be done.
05:02And if ejection fraction is less than 40 percent and any positive ischemia, then laparoscopy
05:09is not performed, open no problem because if it is surgery is must, open can be performed
05:17because in open intraoperative intra-abdominal pressure is not increased.
05:22But laparoscopy why it is problem because venous return will decrease.
05:27So, that is why any patient who has COPD and cardiac disease and decrease venous return,
05:34you should not do laparoscopy.
05:37Another problem is that it create decrease in tidal volume.
05:44In the same study, they observe that what is the effect of tidal volume.
05:50At 6 millimeter of mercury pressure, there is no change in tidal volume, no change in
05:57TV, tidal volume was same.
05:59Normal tidal volume is how much 500 ml.
06:02With each breathing, we inhale 500 ml in and we put 500 ml out.
06:08So, in normal there was no problem, but once 12 millimeter of mercury pressure was done,
06:14there was 50 ml reduction in the tidal volume.
06:19So, it was only 450.
06:22When 18 millimeter of mercury pressure was done, then there was 150 ml reduction in the
06:29tidal volume.
06:30And when there was 24, then dramatically 300 ml reduction in the tidal volume.
06:38That is why patient died because if 500 is required, only 300 ml was given.
06:46And remember, whenever lung is in problem, heart is compensating.
06:50So, already tidal volume is also decreasing and venous return is also decreasing.
06:55So, lung cannot compensate heart, heart cannot compensate lung.
06:59Whenever we have a heart problem and we need more, then what we do?
07:03We have a tachypnea, breathlessness.
07:05Why?
07:06Because more oxygen at least will go, so that heart is not working, then lung will compensate
07:11it.
07:12And if lung is not working, heart is taking tachycardia.
07:16So, that will compensate, but here both the side is a problem.
07:20Heart is also decreasing the venous return and the lung is also decreasing tidal volume.
07:25And that is why at 24, the death may happen.
07:29And even in 18 or 12, where only 50, 100 or 150 ml reduction in the tidal volume is there.
07:40If patient has COPD, then that also can precipitate the acute respiratory syndrome.
07:47Why?
07:48Because COPD patient like tuberculosis, bronchiectasis, bronchial asthma, there 50 percent of lung
07:55is already diseased.
07:56Am I right?
07:57Tuberculosis is there, bronchiectasis is there.
08:01And there were any how compensating with the remaining respiratory reserve.
08:06And now we, if we will decrease further tidal volume because of pressure over the diaphragm.
08:11Why tidal volume decreases?
08:13Because of pressure over the diaphragm.
08:14Because once the pressure over diaphragm, lung cannot fully expand.
08:18And that's why tidal decreases.
08:21So, already 50 percent of lung is damaged by COPD and then little decrease in the tidal
08:26volume can create problem.
08:28So, that's why we should not perform any patient who has chronic obstructive pulmonary
08:33or tidal.
08:34You have decreased tidal volume, decreased cardiac output.
08:38Third problem of the CO2 is hypercarbia.
08:41Unfortunately, CO2 has one big problem that it is 200 times more absorbable than oxygen and
08:5320 times more absorbable than room air.
08:56Absorbable means it get absorbed by the pitonial membrane.
09:00Our pitonial membrane is a semi-permeable membrane.
09:04That's why nephrologists are doing pitonial dialysis because it can exchange the fluid very
09:12fast even urea and even sodium potassium.
09:15So, pitonium is very good that it is a permeable membrane.
09:19So, once we put the CO2 inside a lot of CO2 get absorbed and then it create hypercarbia.
09:27There will be hypercarbia means CO2 concentration in the blood increases.
09:35As soon as hypercarbia happens then there is cerebral arteriolar dilatation.
09:47Cerebral arteriolar dilatation will happen.
09:54Cerebral artery will start dilating.
09:57Why?
09:58Due to hypercarbia CO2 crosses blood brain barrier and once CO2 enter into the brain, the brain
10:05get disturbed and it gives command to the artery that dilate I want more oxygen.
10:09Cerebral arteriolar dilatation and due to cerebral arterial dilatation there will be cerebral edema.
10:16Cerebral edema and once the cerebral edema develop then the brain give command to the heart that
10:28I am in trouble create bradycardia and heart rate decreases that is called bradycardia.
10:36It means initially there was 70 per minute now it is 60 and that 60 will create further hypercarbia.
10:47Because initially there was 72 time the blood was passing through the lung.
10:53So, it was getting more time to get purified more time to throw the CO2 out and take oxygen in.
10:59But now it is 60 and then it will create further accumulation of CO2.
11:05Further hypercarbia, further cerebral arterial, further cerebral edema and ultimately death can happen.
11:12And if death happen and if any inspection happen, then they will ask you that do you have capnograph?
11:27And capnograph is essential and not having capnograph is a medical legal issue.
11:33And capnograph is measuring our ETCO2, end tidal CO2 concentration.
11:40So, in laparoscopy operation theatre, capnograph is must.
11:47Without capnograph, if you do the laparoscopic surgery and if anything goes wrong, you may be
11:55able to get the medical negligence and penalty will be there.
12:02So, if you do the open surgery, you need 5 parameter monitor.
12:08In open surgery, first parameter is NIBP that is non-invasive blood pressure monitoring.
12:16Second, you need ECG.
12:19Third, you need plethysmograph.
12:22Plethysmograph means graph of the pulse.
12:27This is plethysmograph.
12:29Fourth is SpO2 means pulse oximetry.
12:35SpO2 means pulse oximetry.
12:39And fifth is you need this respiratory rate.
12:53And if you are a laparoscopic surgeon, then you need 6 ETCO2 that is end tidal CO2 concentration.
13:03And seventh, temperature to see hypothermia.
13:08These are the seven parameters.
13:11And you know if you will buy from BPL that is a popular company and five parameter monitor,
13:17it will cost you only 50,000 rupees.
13:20But as soon as you go to seven parameter, they will ask you 1 lakh 50,000 rupees, 1 lakh extra
13:27for just adding ETCO2.
13:30Although it is a very small machine, just it is attached with the endotracheal tube and
13:35attached to the monitor.
13:37But they charge you more because they know that you are laparoscopic surgeon.
13:41So, seven parameter monitor is required.
13:45So, CO2 now, normally also we excrete CO2.
13:52Right now, we are sitting and if someone will end tidal means at the end of expiration, measure
13:59how much CO2 is in our breath, then it will be 20 or less than 20.
14:06If you will start running fast, suppose someone is coming with a pistol to kill you and you
14:13run fast, fright and fight stimulation is there.
14:18Then your ETCO2 become 50, 55 and you will feel the warm inside your head and you see pulsation,
14:29you feel pulsation inside your brain.
14:32you feel pulsation inside your brain.
14:33But at that time, our body has adrenaline secretion.
14:38So, that adrenaline is not allowing the bradycardia to happen.
14:43Rather, it creates tachycardia and tachypnea.
14:47So, that is why if you are in fight or fright mode, you have breathlessness and your pulse
14:54is 120, 140.
14:56Am I right?
14:57Marathon race or something, sports or very vigorously you are playing or gymming.
15:05You have a tachycardia and tachypnea because our body secretes adrenaline.
15:11But anesthetized patient, they do not have adrenaline stimulation.
15:17So, they get bradycardia rather than tachycardia and this viscous circle and then patient will
15:27die.
15:28So, that is why it is mandatory that ETCO2 should be there.
15:32But normal patient ETCO2 can be tolerated.
15:36Any tidal CO2 concentration, if it is high, he can tolerate.
15:41But if 50 percent of lung is already diseased, immediately it go to 50.
15:47And remember, if it is CO2 is 20 to 30, your anesthetist will be happy.
15:57If it go more than 30, he will increase the rate of respiration.
16:09What he will do in the ventilator?
16:11It was 12 per minute, he will make it 18 per minute.
16:15So, patient is intubated, rate of ventilation increases CO2 started washing out.
16:23If still it is going, it is become 40.
16:28Then he will tell you that, sir, decrease the intra-abdominal pressure.
16:34He will object you that, please decrease the intra-abdominal pressure.
16:39You were working at 15, he will tell you to decrease to 12.
16:44If you were working on 12, he will tell you that, sir, ETCO2 is increasing, decrease to
16:5110.
16:52And if it is 10, he will get 8.
16:54Less than 8, unfortunately, we cannot work.
16:57Because there will be no space in the abdominal cavity.
17:01If that also is not working, it is going 50.
17:05Then he will increase the rate of respiration to double.
17:10Double means, now it was 12, it is 24 per minute.
17:16But remember, unfortunately, increasing more than 24 will harm.
17:22Because maximum rate of ventilation can be increased to 24.
17:26Suppose he will make 30 or 40, it will not work.
17:29Because it will be so fast that, there will no exchange of the gas.
17:34It will be without any benefit.
17:36Rather, it may decrease the CO2, oxygen and there will be problem.
17:44If it is more than half an hour, 30 minute, up to 30 minute, if it is considered more than
17:5250, then there is a chance that patient will go to unconscious.
17:58Most operatively, patient you might have seen sometime that anesthetist wants to reverse
18:04the patient from out of anesthesia and patient is not opening the eye.
18:09That happens due to increase ETCO2 and then another problem happen.
18:14Less trained anesthetist what they do that if the ETCO2 is going 40, 50 and tidal volume
18:21they say less.
18:22Tidal volume was 500, now it is only 300.
18:27Then they increase the pressure to compensate the tidal volume.
18:32Because nowadays, they do not do by hand by ambu bag.
18:36So ventilator is doing, so increase the pressure.
18:39And if increased pressure is there, ventilator is trying to inflate the lung and diaphragm is
18:47trying to not let the lung inflate it.
18:50So what had happened?
18:51Terminal alveoli will start rupturing.
18:54Terminal alveoli of the lung rupture and due to that pulmonary edema develops that will
19:03create pulmonary edema.
19:06There may be death and it can lead to death.
19:17You might have seen some of the patient postoperatively anesthetist is doing a lot of suction and froth
19:23is coming from the mouth.
19:25That means that anesthetist is not changed, not good and he has ruptured the pulmonary, ruptured
19:34the terminal alveoli and that is why pulmonary edema has developed.
19:39So, good anesthetist they never increase the tidal volume in the ventilator.
19:45What they increase is rate of ventilation.
19:48If tidal volume is 300, they will ask you to decrease the pressure.
19:53So, that automatically tidal volume should increase.
19:56They will not increase the ventilator pressure.
19:59If ventilator pressure is increased, diaphragm is not allowing to expand and ventilator is
20:04saying that you have to expand and then terminal alveoli put put rupture.
20:08Multiple terminal alveoli will puncture and then edema develops.
20:13So, that is why never increase the rate of this pressure of ventilator increase rate of
20:20ventilation.
20:21And if you have a ETCO2, you are safe because if in spite of decreasing the rate of ventilation
20:30and in spite of decreasing your pressure, if still the ETCO2 is high, he will tell you
20:37to convert to open because this person cannot tolerate.
20:43That is why medical legally it is important and every 15 minute anesthetist has to write
20:51on the anesthesia seat that what was the pressure.
20:56It is CO2.
20:57He has to write medical legally it is important otherwise he will be punished.
21:03So, this is necessary to keep in mind.
21:06Now, if the patient is already COPD and cardiac disease, ETCO2 can be big problem.
21:14Another important thing you should take care that you should not give Ondansetron in the
21:20laparoscopy during the anesthesia.
21:25So, sometime Ondansetron induced bradycardia happens.
21:37You can see Ondansetron is one of the most commonly used anti-emetic and it creates severe
21:44bradycardia and hypotension.
21:46There are hundreds bradycardia after intravenous Ondansetron and Assystol rare adverse effects
21:53of Ondansetron hypotension bradycardia a lot of studies performed.
21:58So, what happened if intraoperatively you will give Ondansetron and if bradycardia happens
22:05you will confuse that may be due to my surgery and due to CO2 not tolerated by patient and
22:15you will confuse and unnecessarily you will open the abdomen.
22:19So, that is why Ondansetron intraoperative anesthetist good anesthetist they do not give and if
22:26they do not know you should tell Ondansetron maddena during laparoscopy because that bradycardia
22:32will be confused with the hypercarbia induced bradycardia.
22:36So, that a small precaution should be taken.
22:41So, question is that if CO2 is that much bad then is there any alternative?
22:48There are many alternative one of the alternative is helium helium helium create less bradycardia
22:59less cerebral edema compared to CO2 50 percent less very safe very good but problem is expensive.
23:11It is very expensive one kg of CO2 although I am exactly not up to date with the current cost
23:21but I have been told that 1 kg CO2 is costing only 150 rupees CO2 come in the cylinder in a liquid
23:31form it is compressed CO2. So, it become liquid just like LPG it is liquid form and then it
23:39is coming in the gas form in the insufflator that is why it is cold once it convert into gas
23:46gas it become cold that is why warmer is required. So, and 1 kg helium is 5000 rupees. So, suppose
23:57in one surgery 5 kg CO2 is used then it will be hardly 750 rupees or something but here it
24:06will be 25000. So, only few hospital of the world they use helium for pneumo plutonium like
24:15some of the Cleveland or Mayo clinic they use helium we cannot afford it. Second gas which
24:24is substitute of CO2 is nitrous oxide N2O remember not nitric oxide nitric oxide is poison in your
24:35exam there is one question that which is good the you many of you tick nitric oxide. So,
24:43because of not reading it carefully so nitric oxide and nitrous oxide sound same but it is very different.
24:52So, nitrous oxide is used for what anesthesia we are using nitrous anesthesia nitrous oxide. So,
24:59nitrous oxide you can create pneumo plutonium that is very good it has many advantage one of the
25:05advantages one of the advantages that it is analgesic. So, it never creates shoulder tip pain no patient
25:12get shoulder tip pain other advantage of nitrous oxide is that your amount of the nitrous oxide
25:20in the boil separators will require only 50 percent normally 40 percent is nitrous 60 percent is oxygen
25:27but now in the ventilator you have to give only 20 percent but one of the biggest drawback is it is explosive. So,
25:36you are not allowed to use any current because if any fire cost is not much I think 500 kg 500 rupees per kg per kg. So,
25:49it is not expensive very much but explosive explosive combustible combustible means it itself get fire. So,
26:00you are not allowed to use coterie if you use any spark boom it will air is not combustible air helps in combustion. But,
26:12air itself does not get fire you put a candle then candle will burn but not this room. But,
26:19if you pull nitrous oxide it will room will burn like petrol nitrous oxide is explosive. So,
26:26any current if you are diagnostic it is very good tubal potency test diagnostic laparoscopy you can do and
26:34it is used a lot by gynecologist for diagnostic laparoscopy. So, explosive third gas which is used is air that is room
26:46air. Room air has little increased risk of air embolism because even if 200 ml it will enter into the you know
27:03vane it can create air embolism but unfortunately it is used in laparoscopy. Most of the rural areas in India they are using air
27:17insufflator and companies are making air insufflator because we do not have a strict government control on the instrument. Government has control on the drugs but here drug
27:32act does not follow on the electronic instrument. FDA is taking care of electronic instrument also.
27:39So, there are many company which is air insufflator like they are making air insufflator and I will
27:47show you how it looks like air laparoscopic insufflator it is there in the air insufflator. These all are available in the
28:00India mart. These are air insufflator. This is CO2 insufflator this is air insufflator and some of them has CO2 and air both. So, these insufflators are available in the market. Inside there is nothing there is just like a pump of the pump of the this aquarium.
28:24They have some regulators and here also it will fix if you fix to 12 it will give only 12 and once 12 will reach it stops and it works. Generally air embolism does not happen that is why people are using it. So, you can use but don't tell my name otherwise you can use.
28:52People are using it is safe but potential risk of air embolism. So, if something goes wrong will be in trouble ideally it should be avoided. Fourth gas is xenon plus argon or not plus minus or better is to or argon. These are the two this is also you but a these are ionizable.
29:20They are ionizable. They are ionizable. They are ionizable means it is only there are these two gases xenon and argon these are conductor of electricity. So, it if you use the coterie it will take the electron from one place and it will pass to the other place. So, if you are using it you are allowed to use
29:50because harmonic because harmonic is not electron because harmonic is not electron it is a friction. Bipolar monopolar cannot be used. So, there are many study done where xenon
30:05nemo peytonium was compared with the co2. So, see xenon is also one of the good gas which you can use but improving the safety xenon but xenon anesthesia in laparoscopic
30:24coalescectomy is good approach. But, you are allowed to use only the only the harmony you cannot use the this monopolar because it is ionizable. So, ultimately if you will see and it is also expensive it is not normally available.
30:31Ultimately see that only the best is the best is the best is the CO2 only. You know why what are the advantage of CO2?
30:38advantage of the advantage of the advantage of the advantage of the advantage of the CO2 is first advantage highly absorbable. So, very less chance of monopolar
30:45monopolar because it is ionizable because it is ionizable. So, ultimately if you will see and it is also expensive it is not normally available. Ultimately see that only the best is the CO2 only. You know why what are the advantage of CO2?
30:57advantage of the CO2 is first advantage highly absorbable. So, very less chance of air embolism. Second is cheaper, cheaper. Third is easily available easily.
31:20Fourth is antiseptic. Why antiseptic? Because once it mix with the petrol fluid it is carbonic acid.
31:32And the fifth is anti combustion. Am I right? It is fire extinguished. So, it is anti combustion.
31:43It will not allow any fire. It will not allow any fire to happen. And ultimately this is the best. But only drawback you have to be careful that patient should be not COPD or cardiac disease.
31:59And another that you should be monitoring monitoring by enditidal CO2 concentration. So, this is the fourth problem. Fourth problem is vipercarbia.
32:11Normal person can tolerate hypercarbia. But patient who is COPD and cardiac disease cannot tolerate hypercarbia. That is why in COPD and cardiac disease gasless laparoscopic surgery is preferred.
32:27In gasless laparoscopic surgery there will be no pressure over the venacaba. No pressure over diaphragm. No chances of hypercarbia. No decrease in tidal volume. And no chances of air embolism. So, gasless has disadvantages.
32:44Now fourth problem is air embolism. With CO2 also air embolism can form. Because if it is up to 2 liter per minute air embolism will not happen. But if CO2 goes more than 2 liter per minute even CO2 can create air embolism.
33:05So, let us see the pathophysiology of air embolism. Here is the heart. This is the right atrium. This is right ventricle. This is left atrium. This is left ventricle. Here we have the arc of aorta.
33:24This is left ventricle. This is left ventricle. This is left ventricle. This is left ventricle. This is left ventricle. This is left ventricle. This is left ventricle. This is left ventricle. This is left ventricle. This is left ventricle. This is left ventricle. This is left ventricle. This is left ventricle. This is left ventricle. This is left ventricle. This is left ventricle. This is left ventricle. This is left ventricle. This is left ventricle. This is left ventricle. This is left ventricle. This is left ventricle. This is left ventricle. This is left ventricle. This is left ventricle. This is left ventricle. This is left ventricle. This is left ventricle. This is left ventricle. This is left ventricle. This is left ventricle. This is left vent
33:54needle has enter into vein remember hypercarbia never create air embolism because hypercarbia
34:05is due to generalize absorption of the co2 from entire peritoneal membrane so they cannot
34:12unite to make a bubble in hypercarbia overall concentration of co2 in the blood increases
34:20in the plasma it increases because co2 absorbable so directly dissolve in the plasma but it
34:28will never make a bubble bubble is formed by two means one is directly your various needle
34:35has enter into vein or during extensive dissection you have the excessive pressure like you are
34:43doing radical hystectomy or liver resection or severe myomectomy and a lot of pressure
34:49is there and one of the venue is open and now co2 will directly enter into that vein just
34:56like iv fluid iv infusion of co2 so this is a bubble and here is a bubble and this bubble
35:04will enter into the this is bubble bubble is entering into the right atrium and then going
35:11to right ventricle and from the right ventricle it will enter into the lung and it will create
35:18pulmonary air embolism and then right heart failure followed by left heart failure if you will
35:25use this air embolism this problem is a lot i am showing you here is the air air insufflator
35:33in my hand and it is turned on as a power but light is yes it is powered on and you can see
35:42here there is it is written co2 and air so if i put and see it is writing what air now can you see it is
35:53writing air here a i r here am i right this is air and they have a warmer also this is warmer you can
36:04increase or decrease the pressure and here i am starting the flow start and see it will start giving
36:13pulsatile and it is on the gas see and i am attaching this gloves and they also give you pulsatile flow
36:22pulsatile flow and see this gloves is distending no co2 cylinder is attached air insufflator and as soon as
36:36this 12 will reach flow will stop we are good but medically legally not good because it is right now it
36:48is why it is flowing because little leak is always there here i cannot make it completely airtight but
36:54if i will make it complete airtight it will stop its own so this is air insufflator and you can use
37:03so but it is risky so what this create air air embolism now i have there are many questions
37:13questions which comes in the exam due to air embolism one of the most important question of air embolism
37:23that anesthetist is working with you
37:29and suddenly anesthetist is disturbed suddenly anesthetist is afraid he is little bit disturbed
37:37standing and he is in hurry to asking adrenaline asking something and he is confused what to do
37:46now what is the possibility air embolism or dbt thrombo embolism
37:55how you will differentiate it is air embolism not dbt
37:58one of the biggest difference in the air embolism is there will be sudden collapse in dbt sudden collapse
38:16will not happen dbt thrombo embolism not dbt thrombo embolism not dbt thrombo embolism not dbt thrombo embolism
38:21dbt thrombo embolism not dbt thrombo embolism in dbt thrombo embolism within few minutes your patient will die
38:35it will not do corrective measure dbt thrombo embolism take hours to die or may be days to die
38:44why let us see the difference
38:46what happens in air embolism that this air bubble comes at the level of this valve this valve is
38:56which valve pulmonary valve here this pulmonary valve as soon as air comes in this pulmonary valve
39:05then immediately what happens that valve will collapse all the blood down
39:14no blood can enter into the pulmonary artery
39:21why because this valve is made for protecting blood to go back it is not made for protecting air to go back
39:32let us make it more simple have you seen the water pump in your village
39:36you have water pump if this water pump takes air what will happen
39:42entire water column drops after that you keep on pumping will it come
39:51it will not come you keep on pumping water will not come
39:55because now air has taken
39:58and this air you will keep on pumping it will not suck the water
40:01water because this valve is made for stopping water to go back not for air to go back
40:09or your car or your generator diesel generator has taken the air
40:16now merely adding the diesel it will not start you have to call the technician
40:21he will open and he will remove the air nowadays expensive car they have a pump
40:27so it itself will suck the this petrol but old car older you know ambassador or fiat
40:35when your petrol is empty and it has taken air just adding the petrol will not
40:41start start your car you have to call the technician and they were opening the tube from carburetor and
40:48pulling it throwing the air out and then connecting it and then it will get a start because once the carburetor
40:55has taken the air it cannot suck the petrol same way your air pump if has taken the air it cannot suck the water
41:04water so there will be complete collapse pulseless present within means seconds present become pulseless
41:13in dvt patient will not get immediately pulseless why because in dvt one clot is coming and once once a clot comes
41:23like suppose this is a clot and clot comes then clot cannot block both the lungs simultaneously
41:31clot cannot clot the all the lobes of the lungs simultaneously it can only block one lobe
41:41but remaining other lung other lobes are working so what happened pulmonary hypertension increases
41:48and then gradually right heart failure and then left heart failure will happen
41:53am i right but here no blood is pumping in the pulmonary artery so absolutely immediately pulseless
42:06another you take and why it is co2 decreases because no blood is going into the lung now
42:13so dead person it is you will increase or decrease it will decrease because there is no blood going into
42:22the lung so no co2 is going into the lung so you will see it was 40 now it is two three four
42:30or zero because completely present is pulseless bp stopped pulse zero
42:38and ascetic is jumping trying to do cpr trying to do he is confused and asking for defibrillator and these
42:47things so what you do immediately take a stethoscope and put in the pulmonary excultatory area
42:57this pulmonary excultatory area is second right intercostal
43:01and once you put the stethoscope you will hear a peculiar murmur that is called meal wheel murmur meal
43:10is m double e l yes not meal meal wheel meal wheel murmur or in some book they describe water wheel murmur
43:22what is this murmur this murmur is the same sound which you might have listened in your bathroom
43:36once your water supply is going to be over you are taking a shower and your water tank who is in the top
43:45of the roof that is getting empty then you might have heard a peculiar sound come sound have you have
43:53listened it why this sound is coming little air followed by some water again little air followed by
44:01some water so it give you sound so it is sound just like a wheel running on the water
44:08sound that type of murmur you will listen and then you can save your present life how to save just turn
44:20the present completely left and fully head down turn the present completely left and fully head down
44:30pulse will come why because as soon as present is left then air has a tendency to go up
44:44so from the right ventricle bubble will remain in the right atrium it will not pass to the right ventricle
44:51am i right and a air bubble which was touching the valve now go to apex of ventricle and blood will touch
44:59the valve if you have water bottle and keep the water bottle like that air go up water have you seen
45:07your old scooter in the village if it does not start they tilt it to one side why they tilt it to one side
45:16because air from carburetor will go out and petrol will enter so they tilt the scooter and then they kick
45:25and then a scooter starts so same way you turn the patient to the left and head down
45:31then blood will come at the level of valve air will go away and air which was entering into the heart
45:38will remain in the vena kava because air always remain up and then pump will start pulse will come back
45:45so in air embolism you must differentiate from the dbt how first in dbt sudden collapse doesn't happen
45:54second it is co2 increases in dbt it decreases in air embolism and the third you have a water wheel murmur
46:04or meal will murmur and fourth turning the patient to the left and head down
46:10will prevent air entering into the lung dbt it will not prevent because it is kacara it is a clot
46:19so if you put head down it will go more because it will go more towards the gravity air go against the
46:25gravity but a clot will go more towards the gravity so turn left turn down no problem nothing happens
46:32air you can save the life of the present immediately turn the present fully and now blood will come
46:39because air bubble will remain in the vena kava and then fresh blood will come and it will remove all
46:45the clots and if your anesthetist is very good then he will use a catheter that is called swain gauss catheter
46:55this is swain gauss catheter this catheter is available and it is called pulmonary artery catheter
47:06so in this he will put it into the atrium and a frothy blood will come out in the jugular vein
47:13on the right side he will put in the atrium and a frothy blood will come out and patient life can be saved
47:21so this is the problem of the air embolism so due to that reason these four factor major factor
47:29laparoscopy should be avoided in the patient who has a cardiac disease and pulmonary disease
47:35but remember this word severe is important if you see in the previous slide it is severe copd and
47:42cardiac disease not the mild mild is okay and that is decrease vena return decrease cardiac output
47:50decrease tidal volume decrease minute volume hypercarbia and air embolism
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