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  • Admar A. In the laparascopy surgery do you have ETT or LMA ?
    and do you use N2O

    • Admar A. laprascopy surgery for histerctomy or cystectomy

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  • Admar A. slide blurr

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    • Abdelazeem E. when we say OFA, does this include no opioids at induction of anesthesia?

      • Jan Paul M. OFA stay for opioid free anesthesia and means no opioid given before or during anesthesia till the last stitch, also not for induction and intubation. if you give an opioid after surgery it is an analgesic, not an anesthetic.. I know that this discussion is more semantic but important to know what you mean with it. Opioids given intra operative could be to block surgical stress, to stop spontaneous breathing to induce bradycardia or hypotension. Opioids given postoperative should work as analgesics and this is best achieved if tolerance did not develop yet due to the high doses given intra operative.

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    • Abdelazeem E. what is your opinion on use of moderate versus deep NMB in laparoscopy?

      • Jan Paul M. depending on the abdominal compliance (abd C) and the starting IAPressure at volume zero (PV0) you might be able to work with a moderate NMB when setting IAP above 12. ( ex if PV0 = 4 and abd C= 0,5L/mmHg you need 4+6=10 mmHg to get 3 liter workspace) with a deep NMB you can drop PV0 to 2 mmHg and use 8 mmHg still getting 3 liter the minimum good workspace) if the patient is obese the PV0 can start at 10 and if male with central obesity C can be only 0,1 L/mmHg meaning that even 20 mmHg is not enough and just gives 1 liter only. A deep NMB is now essential to reduce PV0 to lets assume 7 ( you have to measure as every patient is different) and this gives now at 20 mmHG 1,3 liter instead of 1 liter...
        If you want to use lowest IAP possible then it helps always to go to deep NMB and drop a few mmHg lower. Next to workspace there should be no movement where you have several options: deep NMB, deep hypnosis ( 2 MAC) or high dose opioids and hyperinflation as the last three will block respiratory centers ut not relax the muscles. However today we know that deep hypnosis, high dose opioids and hyperventilation are not without any risk while deep NMB is at no risk on the condition that you measure NMT and reverse till a TOF of 100 %

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    • Abdelazeem E. we still not open the OR fully for elective cases due to covid. I learned yesterday that you already back to normal. Do you have any prognostic tools which we can put ahead during planning of reopening of the OR for elective cases?

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      • Abdelazeem E. is there evidence that viral transmission can happen during pneumoperitoneum and also with smoke of the cautery: with reference to covid era.

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        • Nebojsa G. I see that Anesthesiologyst work "alone", without anesthesia nurse. As I uderstood, scrub nurse is asistent to anesthesiologyst and surgical team. Is it usual in Belgium?

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          • Abdelazeem E. yesterday we heard of reduced opioid technique arguing with OFA. Do you have any comment?

            • Jan Paul M. As I replied yesterday: it takes time to be able to reduce opioids but on one condition and that is that you add other drugs that suppress the surgical stress! If giving enough you can avoid all opioids intra operative even without loco regional blocks and classical analgesics but you will classical analgesics, loco regional blocks if possible post operative. AND in major surgery without loco regional you will need as analgesic ( not as anesthetic) after awakening a low dose of opioids in some patients and this not wrong and still opioid free anesthesia and indeed NOT opioid-free analgesia. the required opioid dose now postoperative is substantial ( 25 to 50%) lower and therefore also the impact on having less opioid side effects as respiratory depression, PONV, ileum just to name some..

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          • Nebojsa G. When you are giving dexamethasone, during induction or some time before surgery. Considering trah it takes time for effect.

            • Jan Paul M. it is essential to load drugs up early before induction or incision, depending on the pharmacokinetics: dexmedetomidine should be given at least 15 min before induction, dexamethasone (no clear studies yet) might be needed before PP insufflation but some studies ( in mice) have shown anti inflammatory effects still when given at end of laparoscopy! Ketamine should be given as a bolus 5 10 min before incision of the skin or other stimulating act, lidocaine iv, magnesium iv are both rapid working and better to give just before or after propofol given the strong vasodilatory effects that can give a warm flush in the head... No need for early loading but if you want to load give them very slowly and diluted, never as bolus if before induction.

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          • Abdelazeem E. Risk of covid transmission during patient hospitalization and surgical procedure, that is now included in the consent form. Is it enough or if covid infection occur the patient can sue the hospital and doctors?

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            See previous comments (11)
            • Abdelazeem E. During covid era, is ERAS program still performed as planned or there is some modification?

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              • Abdelazeem E. pls describe your opioid free anesthesia protocol?

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                • Samah A. Thank you for sharing your experience with us.
                  In our reality is not easy to select one team for all opeartins

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                  • Abdelazeem E. in my setting we use moderate NMB and everybody happy with it. Even the recovery is excellent using it. Do you have a comment on moderate NMB?

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                    • Nebojsa G. At what level of spine you place epidural for colorectal surgery?

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                      • Jan Paul M. low opioid dose intra operative is nice concept but only on one condition and that is "giving other drugs or using loco regional infiltration in combination to block sympathetic and humoral reactions." The very high dose opioids intraoperative were needed when no other drugs were given to block these unwanted reflexes, certainly in major surgery.

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                        • Jan Paul M. toxic dose is described at dose of 5 mg/kg or higher although this overdose is just giving deep anesthesia as you said totally different from levobupivacaine that is cardio and cerebral toxic on overdose

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                          • Jan Paul M. Be very careful that no drapes are laying between skin and bump of trend guard !! or patient slides off

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                            • Jan Paul M. IL 6 / IL 10 ratio is all about peritoneal inflammation and this is indeed dramatic reduced when IAP is kept below 8 mmHg. The big interesting question is indeed if this reduced IAP by improving bowel perfusion reduces also the ileus. However you have to control for opioids as these are the number one factor inducing ileus. If you use OFA it would be easier to verify the hypothesis...

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                              • Jan Paul M. the CO2 absorption through the peritoneum increases after 30 min PP. Airseal can reduce the absorption by reducing the ischemia as air leaks slowly inside, and just 4 % O2 is already enough to keep the peritoneum longer alive when IAP are higher than 8 mmHg.

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                                • Jan Paul M. surgeon is faster in recognizing as PTC is not automatic and the diaphragm can still move when PTC = 1

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                                  • Jan Paul M. Matthieu understood the physiology very good. congratulations

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                                    • Jan Paul M. congrats to all

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                                      • Abdulla Rasheed Hassan Ahmed A. Nice lectures which increasing our knowledge, my appreciation to all the lecturers. thanks.

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                                        • Gazi C. Thanks a ton for very informative presentation.Kindly share the PowerPoint presentations.

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