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ANAESTHETIC CHOICES FOR LITHOTRIPSY

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LITHOTRIPSY

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ANAESTHETIC CHOICES FOR LITHOTRIPSY

  1. 1. Anaesthetic choices for lithotripsy Dr Nida Fatima Department of Anaesthesia and Critical care, JN Medical college and hospital AMU aligarh
  2. 2. Urolithiasis • Prevalence of stone disease -1% to 15%. • Varies- age, gender, race, and geographic location. • stone formation - migrated -lower to the upper urinary tract. • once limited to men is increasingly gender blind.
  3. 3. UROLITHIASIS Forced Diuresis Alkalisation of urine Tamsulosine with hydration Extra Corporeal Shockwave Lithotripsy Percutenous Nephro- lithopexy Uretro- Reno scopic Lithotripsy Cysto- litholapexy Pyelo/Nephro /Cysto/ Urethro- lithotomy Nephrectomy If non functional kidney Endoscopic removal
  4. 4. • Lithotripsy( Greek) meaning "stone crusher“. • Techniques: • Extracorporeal shock wave lithotripsy • Laser lithotripsy • Electro-hydraulic lithotripsy • Mechanical lithotripsy • Ultrasonic lithotripsy What is lithotripsy?
  5. 5. • Introduction ESWL in 1980. • 85% of renal calculi - treated • Externally generated, harmlessly penetrated shock waves, provide pressure (900-1000 bar) on a kidney stone to disintegrate it into smaller granules. Why lithotripsy?
  6. 6. Extracorporeal shock wave lithotripsy (ESWL) • Disintegration of urinary stones in the ureter and kidney. • High-energy waves (20 kilovolts)- focused on ureter or kidney. • Lithotripter uses “R-wave ECG”- trigger for shock wave - refractory period of the cardiac cycle.
  7. 7. When lithotripsy?
  8. 8. MANAGEMENT OF RENAL CALCULI by ESWL < 2cm in diameter and/or surface area < 500 mm2 Treatment : ESWL mono-therapy > 2cm in diameter and/or surface area > 500 mm2 Treatment : PCNL +/- ESWL Combination therapy
  9. 9. Lithotripter • Comprises of: • spark plug • Energy reflector • Energy concentrator • Fluoroscopy • ultrasound
  10. 10. Spark plug Energy vaporize water external shock wave water bath/cushions Release energy patient’s body stone generate Focussed on Passed to hits Crushed to pieces
  11. 11. - The sudden expansion of air bubbles created sets up a pressure wave (shock wave) - Focused onto F2 focus - Exponential reduction energy of wave beyond F2.
  12. 12. EFFECTS OF RESPIRATION • For shock waves -most effective- stone at F2 focus during treatment. • Because of movements during respiration… The stone is likely to move in and out of focus. • To increase the efficacy of the treatment : • decreased tidal volumes ,increased respiratory rates, high-frequency jet ventilation .
  13. 13. Physiological effects of lithotripsy • Mechanical stimulation of myocardium and conduction system…arrhythmias. • Atrial premature contraction • Ventricular premature contraction • Atrial fibrillation • Supraventricular tachycardia • Ventricular tachycardia
  14. 14. When a patient is placed in a water bath: Problems • Cardiac preload is augmented • Increase in CVP and PCWP • Compression -peripheral venous system. • ↑ SV and cardiac output of 30%. • Hydrostatic pressure on the chest: ↓ FRC by 30% and VC by 20%. • ↓tidal volume , ↑ work of breathing
  15. 15. Changes on Immersion during Lithotripsy Cardiovascular Increased Central blood volume Increased Central venous pressure Increased Pulmonary artery pressure Respiratory Increased Pulmonary blood flow Decreased Vital capacity Decreased Functional residual capacity Decreased Tidal volume Increased Respiratory rate
  16. 16. • Newer lithotripters no need of water bath. • universal table for fluoroscopy. • energy can be focused more precisely. • less painful.
  17. 17. Renal changes • Diuresis, natriuresis, and kaliuresis. • ↓ADH and renal prostaglandins Temperature changes: • This heat transfer is augmented -vasodilation produced by general or epidural anesthesia. • Hypothermia and hyperthermia have been reported.
  18. 18. • The pathogenesis -multifactorial. • - Both cutenous and visceral nociceptors Visceral nociceptors – • periosteal, • pleural, • peritoneal, • musculoskeletal pain receptors PAIN
  19. 19. Variables associated with pain • the type of lithotriptor, • size of focal zone • shockwave peak pressure, • size and site of stone burden • area of shockwave entry at the skin, • location of the shockwave front
  20. 20. Special considerations!!! • Women of childbearing age need to undergo- a pregnancy test. • Abdominal aortic aneurysms with calcium deposits • orthopedic prostheses - kept out of the path of shock wave. • Lung tissue -susceptible to shock wave injury- Hemoptysis and pulmonary contusion. • Styrofoam padding.
  21. 21. • No incisions • No surgery • No lengthy hospital stays • No lengthy recovery periods Advantages of lithotripsy
  22. 22. • Some discomfort. • Medicine to prevent infection. • Passing sand-like particles in urine Disadvantages of lithotripsy
  23. 23. • Weight > 300 pounds (140 kg) • Pregnant (absolute NO) • Bleeding diathiasis (relative) • Non- functional kidneys • Pacemaker in-situ • Contraindicated to anaesthesia or x-rays. Who should not have lithotripsy?
  24. 24. Laser Lithotripsy • Ureteral stones low in ureter and not amenable to ESWL. • laser beam of 504-nm. • organic green dye. • Laser beam -absorbed by the stones • pulsatile energy is released - disintegration of the stones pulsed dye laser
  25. 25. • The anaesthesia method for ESWL procedures Depends upon: • The level of patient consciousness • The spontaneous breathing ability • Need for intensive monitoring • Anaesthesia recovery time. Anaesthetic choices for lithotripsy
  26. 26. • Patient’s ASA class. • Model of lithotripter – high-energy lithotripters may require deeper level of sedation • Availability of certified anaesthetist or nurse anaesthetist. • Location of lithotripsy treatment
  27. 27. General anesthesia Analgesia- sedation Spinal anesthesia Epidural anesthesia Flank infiltration ± intercostal blocks Monitored anesthesia care Conscious sedation Anaesthetic choices for lithotripsy
  28. 28. Conscious Sedation • An altered state of consciousness • Minimizes pain and discomfort - analgesics and sedatives. • Patients able to speak and respond. • A brief period of amnesia may erase the patient’s memory of the procedure.
  29. 29. • Benefits: • Ease of administration • Minimal equipment. • Rapid recovery time.
  30. 30. • Drawbacks: • Diaphragmatic excursion • Increase treatment time • Decrease effectiveness of the treatment. • Unpleasant memories
  31. 31. Monitored Anesthesia Care (MAC Anesthesia) • Patient protects the airway • Requires active participation of anaesthesiologist. • Can induce loss of normal protective reflexes • Loss of consciousness • The level varies widely during a single case and from case to case.
  32. 32. • Benefits: • A deeper level of anaesthesia • Diaphragmatic excursion is reduced • Improving treatment times and effectiveness
  33. 33. • Drawbacks: • Must be administered by qualified anesthesia personnel. • Diaphragmatic excursion when anaesthesia is not deep enough • This can increase treatment time and/or decrease the effectiveness of the treatment
  34. 34. General Anesthesia (GA) • Drug-induced loss of consciousness • Cannot be aroused, even by painful stimulation. • Impaired respiratory and cardiovascular function • If PPV → Securing airway using: • Laryngeal Mask Airway • Endotracheal Intubation
  35. 35. Benefit • Rapid onset • Control of patient movement. • Ventilation parameters –controlled. • Decrease stone movement with respiration, • Effective stone targeting and fragmentation.
  36. 36. Drawback • Morbidity and potential mortality • Longer hospital stay, • Expensive • Prolonged recovery • Strict monitoring • Equipment and personel
  37. 37. GA preferable - Children, - Extremely anxious individuals, - Anticipated lengthy treatment • bilateral ESWL, • concomitant renal and ureteral stones, • calculi composed of cystine, or brushite, COM.
  38. 38. MAC VS GA • MAC • Rapid recovery • Bypasses PACU • Fastracking surgery • G.A • Prolonged recovery • Shorter duration of ESWL procedure • Less opioids required
  39. 39. Regional Anesthesia • Easier to provide. • Controlled loss of sensation. • Better analgesia. • Methods for shock wave include: • Spinal Anesthesia • Epidural Anesthesia
  40. 40. Epidural anesthesia • Early recovery , good analgesia. • LOR with saline • Smallest amount of air if necessary-provides an interface → dissipation of shock wave energy and local tissue injury.
  41. 41. Spinal anesthesia • Rapid onset • Hypotension is higher. • The incidence of hypotension with general , epidural, and spinal anaesthesia was 13%, 18%, and 27%, respectively.
  42. 42. Regional anaesthesia • Drawbacks • Postdural puncture headache (42%) • Transient neurological symptom • Urinary retention • Pruritis • Hypotension
  43. 43. • Flank infiltration ± intercostal blocks. • L.A infiltration of flank ± intercostal blocks + intravenous sedation →adequate anesthesia avoids hypotension. • Analgesia -sedation Intravenous analgesia- sedation in various combinations has been used successfully

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