PACRIM – Anesthesia

Debra Morrison, MD, anesthesiologist at UCI gave a talk on anesthesia and robotic prostatectomy. While many of the points she reviewed have been covered elsewhere, there were a couple of suggestions that she had that I had not heard of before. She mentioned that with the extreme Trendelenburg position not only is the diaphragm pushed up into the chest but the trachea can be displaced towards the head. This can result in the ET tube migrating into the right mainstem bronchus and an abrupt increase in difficulty ventilating the patient. She is a pediatric anesthesiologist so perhaps she has seen this in that age group but I have not seen or heard of it happening in an adult. Still, it is worth keeping in mind in case you ever experience a sudden deterioration in the patient’s status. The problem may be corrected by simply withdrawing the tube a cm or two until ventilation is returned to normal. At least try that before aborting the procedure and breaking everything down.

The other interesting point that she made was with regard to the difference in somatic v. visceral pain. We make much of the reduced somatic pain with laparoscopy. Dr. Morrison has the unique perspective of having been a patient who has undergone both an open and a laparoscopic procedure. She agrees that the somatic pain is distinctly less but she did experience quite a bit of visceral pain. She recommends instilling into the abdomen at the end of the case 0.25% Marcaine at a dose of 1mg/kg of body wt.
Has anyone had problems with ET tube positioning or experience with intraperitoneal Marcaine?

1 thought on “PACRIM – Anesthesia

  1. Joe Culver, MSN, CRNA

    I have been involved in hundreds of robotic cases and I do run into ETT migration. There are studies that state the diaphragm can push the trachea up to 2cm.
    This could easily push the ETT into the right mainstem. With the somatic pain issue, there is a device that will infuse a set amount of local anesthetic into the abdomen. The device is called the On-Q pump. Patient satisfaction was excellent.

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