Background. Anesthetic management of patients with morbid obesity during bariatric surgery presents a number of problems, including “difficult" vascular access, “difficult" airways, increased risk of aspiration, changes in the pharmacokinetics of anesthetics, and an increased risk of postoperative respiratory depression associated with opioids. Methods. Case description Patient 32 years old, height 162 cm, body weight 200 kg (body mass index 76.2 kg/ m2) underwent surgical treatment for morbid obesity (gastroentero bypass) using combined anesthesia (general anesthesia with desflurane combined with epidural analgesia ropivacaine 2 mg/ml). Results. Ultrasound navigation was used to catheterize the peripheral vein and insert an epidural catheter. Also, due to the high risk of difficult airways (according to the MOSCOW TD scale - 4 points), the patient underwent fiberoptic orotracheal intubation with in consciousness with sedation by dexmedetomidine to level -1 on the Richmond excitation-sedation scale. Early activation of the patient was achieved by controlled anesthesia and multimodal analgesia in the postoperative period. Analgesia after surgery using prolonged epidural administration of 0.2 % ropivacaine at a rate of 4-8 ml/h, intravenous paracetamol 1 gram every 8 hours. 2 hours after the end of the operation, the patient sat down on the bed with her legs down and got up for the first time after 6 hours. On the second day, she was transferred to a specialized department with prolonged epidural analgesia, the duration of which was 72 hours. Complications were not observed in the postoperative period. The patient was discharged from the clinic on the eighth day after surgery in a satisfactory condition without active complaints. Conclusion. In this clinical case, the chosen tactics of postoperative analgesia made it possible to achieve good analgesia, conduct early activation of the patient, and begin early rehabilitation procedures.
Introduction. Robot-assisted laparoscopic radical prostatectomy (RALRP) is the most effective treatment option for localized prostate cancer. Special conditions of the surgery (Trendelenburg position and pneumoperitoneum) lead to negative physiological consequences. Objectives. Systematize current data of the effect of total intravenous anesthesia (TIVA) with propofol or inhaled anesthesia with sevoflurane or desflurane on undesirable perioperative events during RALRP in patients with prostate cancer. Materials and methods. Search of PubMed, Embase, Cochrane Central Register of Controlled Trials, Web of Science, International Standard Randomized Register of Controlled Trials, and ClinicalTrials.gov until February 2021. Results. The review included 7 randomized controlled trials. Undesirable perioperative events were nausea and vomiting, decreased jugular venous bulb blood oxygenation, increased optic nerve sheath diameter as a surrogate marker of high intracranial pressure, and high intraocular pressure. Conclusions. We found weak evidence that propofol-based TIVA may have safety advantages over inhaled anesthetics in the anesthesia provision of RARP.
Introduction. Prostate cancer remains the most common urological malignancy, and robot-assisted radical prostatectomy (RARP) is the most effective treatment option. Special conditions for operation (Trendelenburg position and pneumoperitoneum) increase the airway pressure and reduce functional residual capacity of the lungs. Objectives. Review of risk factors for disorders and various interventions to improve pulmonary function and reduce the adverse physiological effects of RARP under general anesthesia. Materials and methods. This review of literature was conducted using the PubMed search engine in electronic databases Medline, Embase, the Cochrane Library and others up to May 2019. Results. A total of 22 studies were searched, including 9 randomized controlled trials. The factor that could worsen gas exchange during RARP was the body mass index 30 kg/m2. It is possible to improve gas exchange by means of recruitment maneuvers. Positive end-expiratory pressure of 5-10 cm H2O improves oxygenation but requires alertness in patients with chronic heart failure and chronic obstructive pulmonary disease. Conclusions. The main risk factors for perioperative respiratory and oxygenation disorders in RARP are pneumoperitoneum and steep Trendelenburg position. The effectiveness of ventilation regimes for the prevention of gas exchange disorders has not been proven. Using the recruitment maneuver and increasing the positive end-expiratory pressure does not improve the respiratory function of the lungs. Further studies with a longer follow-up period are needed to determine the clinical efficacy and safety of RARP.
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