What the Anesthesiologist Should Know before the Operative Procedure

The anesthesiologist should be aware of several issues surrounding a patient presenting for a cholecystectomy. The nature of the operative procedure, whether the plan is laparoscopic or open, and the urgency or elective nature of the procedure are important factors. Additionally, the nature of the underlying disease necessitating gallbladder removal is also key and may influence the anesthetic plan. Occasionally a patient’s comorbidities may influence the surgeon’s approach, and a discussion should be undertaken prior to induction in such cases.

1. What is the urgency of the surgery?

What is the risk of delay in order to obtain additional preoperative information?

Patients presenting with acute cholecystitis and/or choledocholithiasis may become acutely ill if not managed promptly. A delay in diagnosis or intervention may result in the patient developing a gangrenous gallbladder with potential perforation and severe systemic illness. An impacted stone may lead to gallbladder obstruction or obstructive jaundice depending upon its location.

Emergent: There are no real indications for emergent cholecystectomy.

Urgent:Acute cholecystitis, acalculous cholecystitis, and gangrene are all indications for urgent surgery. Patients must initially be managed medically with antibiotics and hydration followed by urgent operative intervention if appropriate. Patients have often been ill for hours, if not days, prior to presenting to the hospital, and appropriate resuscitation and electrolyte correction should be undertaken prior to them presenting to the operating room. For patients with a gangrenous gallbladder and sepsis, percutaneous cholecystostomy may be considered especially in patients with multiple comorbidities. If surgical intervention is deemed appropriate, it should be undertaken promptly. An understanding of the patient’s physiologic status prior to the illness should be sought as well as the degree of systemic involvement of their current disease state.

Elective: As for any elective procedure, a routine history and functional status should be obtained from the patient. The nature of the disease necessitating cholecystectomy should also be sought. If necessary, an elective procedure should be postponed so that an appropriate medical workup may be obtained.

2. Preoperative evaluation

When evaluating a patient for cholecystectomy, a routine history should be obtained with careful emphasis placed upon the cardiac, pulmonary, and gastrointestinal systems.

An appreciation for a patient’s cardiac status is of paramount importance in preparing for a cholecystectomy. Since the vast majority of patients will undergo a laparoscopic procedure, the anesthetist must understand the potential physiologic perturbations that will occur as a result of abdominal insufflation and their effects on a patient’s cardiac performance.

Pulmonary status is also of key importance when preparing a patient for cholecystectomy. Whether the procedure is performed laparoscopically or open, pulmonary reserve and function will be affected. Any underlying pulmonary disease should be sought and appropriately evaluated prior to surgery.

The gastrointestinal system is of obvious importance to evaluate prior to the start of anesthesia. As mentioned earlier, the pathology requiring cholecystectomy should be sought prior to induction. Indications for surgery include acute cholecystitis, acalculous cholecystitis, symptomatic cholelithiasis, and cancer. The patient’s NPO status should also be verified and the possible need for a rapid sequence intubation should be considered. Depending on the nature of the underlying disease, significant hepatobiliary synthetic and metabolic dysfunction may be present. Although this is unlikely to be an issue for elective cases, the degree of underlying disease may influence the choice of drugs in patients with marked impairment in liver and biliary function.

Medically unstable conditions warranting further evaluation

Significant cardiac pathology including heart failure, coronary disease, or valvular lesions should be evaluated prior to anesthesia as well as major pulmonary disease such as severe asthma, COPD, or pulmonary hypertension.

Delaying surgery may be indicated if: the patient is currently unstable from a hemodynamic or respiratory standpoint. If surgical intervention is urgent, consideration should be given to altering the plan to a less invasive mode such as percutaneous drainage or an endoscopic procedure if it is appropriate.

3. What are the implications of coexisting disease on perioperative care?

Patients with significant coexisting disease may need to be medically optimized prior to coming to the operating room. Evaluation by the patient’s primary care physician or specialist prior to elective surgery is optimal. Postoperative care is dictated by the patient’s comorbidities and their illness at presentation. Occasionally, a monitored or intensive care unit setting may be needed for patients with severe systemic illness.

Perioperative evaluation

Routine preoperative testing should be guided by the patient’s coexisting diseases and available guidelines. If a patient has known significant pulmonary or cardiac disease, preoperative consultation with their specialist or primary care physician is ideal.

Perioperative risk reduction strategies

Cardiac disease should be evaluated and managed according to the most recent ACC/AHA guidelines. As part of a risk reduction strategy, consideration should be given to continuation of medications with proved or likely benefit such as beta-blockers, statins, and nitrates. For patients with pulmonary disease, the importance of coughing and deep breathing as well as early ambulation should be emphasized preoperatively to help prepare patients with appropriate expectations for their postoperative course. The benefits of smoking cessation should also be discussed and encouraged during preoperative consultation.

b. Cardiovascular system:

Acute/unstable conditions

Any acute or unstable cardiac disease whether it be coronary disease, decompensated heart failure, or severe valvular disease should be managed in conjunction with a cardiologist prior to the patient coming to the operating room for an elective cholecystectomy. If the procedure is urgent, consideration should be given to performing a less invasive procedure such as percutaneous biliary drainage or ERCP rather than intervening surgically. A laparoscopic cholecystectomy has the potential to exacerbate underlying cardiac disease in several ways. Abdominal insufflation raises intra-abdominal pressure and may either augment preload or impair it depending on the patient’s volume status. Insufflation and elevated CO2 levels may increase SVR and potentially worsen heart failure or regurgitant valvular lesions by increasing afterload.

Baseline coronary artery disease or cardiac dysfunction—Goals of management

Stable coronary disease requires continuation of a patient’s current cardioprotective regimen. Beta blockers should be continued through the day of surgery and administered by the anesthetist if necessary to optimize rate control. Statins, aspirin, and nitrate therapy should also be continued in the perioperative period. In patients with drug eluting stents (DES), aspirin must be continued, but the need to maintain Plavix should be made based on the age of the stent and in consultation with the patient’s cardiologist. Afterload reducers such as ACE inhibitors and angiotensin II receptor blockers (ARBs) should be dealt with on an individual basis and are managed largely by the preference of the anesthetist.

c. Pulmonary:

COPD

In order to optimally manage a patient with COPD in the perioperative period, and understanding of the patient’s baseline pulmonary status and physiology (whether they suffer from emphysema or bronchitis) is key. Their functional capacity, degree of dyspnea and medical regimen should be sought. Any recent exacerbations or pulmonary illnesses should also be identified. If available, pulmonary function tests (PFTs) may be helpful to gauge disease severity, but surgery does not need to be delayed in order to obtain them. Use of oral steroids should be documented so that consideration can be given to stress dose administration should the patient become critically ill during or after surgery.

Since almost all patients undergoing laparoscopic or open cholecystectomy will be intubated and mechanically ventilated, the expected physiologic perturbations associated with this need to be understood. A decrease in functional residual capacity (FRC) occurs in the supine position and is then exacerbated upon induction of anesthesia. Patients with emphysema have an increased dead space, and a large arterial to end tidal CO2 gradient may be present due to the patient’s underlying obstructive disease. CO2 elimination during insufflation may become problematic in patients with severe obstructive disease, possibly even necessitating conversion to an open cholecystectomy. Expiratory gas flow resistance may be increased and the expiratory flow tracing should be observed for the presence of auto-PEEP and potential air trapping.

Appropriate postoperative planning should be made prior to surgery in patients with severe underlying pulmonary disease, and the potential for post-op intubation should be discussed with the patient if their disease state warrants it.

Reactive airway disease (asthma)

Similar to patients with COPD, functional capacity, medical regimen and recent exacerbations are important indicators of the severity of a patient’s reactive airway disease. Their response to bronchodilators and need for rescue inhalers or nebulizers should be sought. Pre-treatment with a beta-agonist such as albuterol may be helpful prior to induction and airway manipulation. In severe cases, a low-dose epinephrine infusion may be helpful. All of the inhaled volatile agents, with the probable exception of desflurane, may also improve pulmonary function due to their bronchodilatory properties.

d. Renal-GI:

Renal impairment and end-stage renal disease are not contraindications to cholecystectomy. However, careful consideration should be given to appropriate drug dosing, and fluid and electrolyte administration should be adjusted accordingly. IV access may be limited by extremity restrictions due to AV grafts or fistulas. Laparoscopic insufflation decreases renal blood flow, and surgical stress is known to stimulate vasopressin release. These two factors combined may lead to diminished urine output, which may increase the challenge of monitoring renal function in those with baseline impairment. Chronic renal insufficiency with a creatinine > 2.0 is also a known risk factor for perioperative cardiac morbidity and mortality and should raise suspicion for underlying coronary disease.

Gastrointestinal disease other than that necessitating cholecystectomy should be sought. Patients with severe gastroesophageal pathology or reflux may need to be managed with a rapid sequence induction, and pretreatment with a nonparticulate antacid is appropriate. Underlying hepatic disease such as cirrhosis should be documented as well as its etiology. A large portion of drugs administered during general anesthesia are metabolized by the liver and dose adjustments may be necessary. Additionally, patients with a higher Child-Pugh or MELD classification have an increased risk of death perioperatively, especially given the intraperitoneal nature of cholecystectomy. Prior abdominal surgeries may influence the surgical duration and possibility of conversion from a laparoscopic to open procedure.

e. Neurologic:

Neurologic disorders may be co-existent in patients presenting for cholecystectomy but are rarely involved in the underlying pathophysiology necessitating gall bladder removal.

Acute issues: Any acute neurologic issue should be evaluated prior to an elective cholecystectomy. Acute mental status changes can be seen in septic patients presenting for urgent surgery secondary to a severely diseased or gangrenous gall bladder. In such cases, appropriate treatment includes antibiotics and surgical removal or decompression of the gallbladder.

Chronic disease: Chronic neurologic diseases should be managed as for any elective surgery. Neuraxial anesthesia, if appropriate for the operation, should be carefully considered in patients who suffer from upper or lower motor neuron disorders.

f. Endocrine:

Underlying endocrine disease should be managed as is appropriate for any elective surgery. Gallstone pancreatitis may impair enzymatic function but is unlikely to impair endocrine function. Systemic illness and inflammation as can be seen during acute cholecystitis may result in elevated cortisol levels with subsequent hyperglycemia; however, intrinsic pancreatic endocrine function should not be affected long term.

g. Additional systems/conditions which may be of concern in a patient undergoing this procedure and are relevant for the anesthetic plan (e.g., musculoskeletal in orthopedic procedures, hematologic in a cancer patient)

N/A

4. What are the patient's medications and how should they be managed in the perioperative period?

Most prescription medications are safe to continue in the perioperative period. However, herbal supplements should generally be discontinued 5 to 7 days prior to elective surgery. There is a paucity of scientific data on over the counter and herbal supplements, but many have known side effects that are unfavorable in the perioperative period. Notably, garlic, ginseng, ginkgo baloba, fish oil, dong quai, and fever few all have the potential to increase bleeding and should be stopped a week prior. Kava, St. John’s wort, and Valerian root may cause sedation and can potentially prolong the effects of anesthesia.

h. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern?

Patients admitted with an acute hepatobiliary process who present for cholecystectomy may be on parenteral opioids and/or antibiotics. Generally, these do not present any major concerns, but recent administrations should be noted as well as repeat dosing requirements in the case of antibiotics.

i. What should be recommended with regard to continuation of medications taken chronically?

Cardiac: Cardiac patients in particular should be instructed to continue their medications, especially beta-blockers, statins, and nitrates. ACE inhibitors and ARBs can be held on the morning of surgery or continued based on the anesthetist’s preference.

Pulmonary: All pulmonary medications should be continued perioperatively, and patients should be encouraged to bring their inhalers from home, especially if they are scheduled for admission to the hospital. The one possible exception to this is theophylline. Although rarely used today, some patients with a reactive component to their airway disease are still treated with this drug, which acts as both a phosphodiesterase inhibitor and adenosine receptor antagonist. Its narrow therapeutic window and potential to cause cardiac arrhythmias, particularly in the era of halothane use, lead to the recommendation that theophylline be discontinued preoperatively.

Renal: End-stage renal disease patients and those with chronic renal insufficiency should continue their medications perioperatively.

Endocrine: Diabetic regimens need to be adjusted given that most patients will be NPO prior to surgery. Oral hypoglycemics should be held on the morning of surgery. Long acting insulin (e.g., lantus) can be continued at its regularly scheduled time and dose. Intermediate acting insulin (NPH) doses should be halved on the morning of surgery, and short acting insulin should be held. Ideally, insulin-dependent diabetics will be scheduled as the first case of the day to minimize the time they are NPO.

Neurologic: Antiseizure medications should be continued perioperatively. It should be noted, however, that some anti-epileptic meds upregulate the cytochrome P450 complex, which can lead to enhanced metabolism of certain drugs metabolized by the liver.

Antiplatelet: Antiplatelet agents in general should be continued, as most surgeons will be able to perform either a laparoscopic or open cholecystectomy with minimal increase in blood loss despite a patient continuing aspirin. However, the decision to stop or continue plavix should be made in conjunction with the patient’s PCP or cardiologist and surgeon and is based upon the patient’s specific risk factors. If a neuraxial anesthetic is being considered for an open cholecystectomy, anti-coagulant therapy should be documented and held if appropriate.

Psychiatric: Psychiatric medications can be continued perioperatively. The one possible exception to this is monoamine oxidase inhibitors (MAOIs). If discontinuation of the MAOI is not possible due to the urgency of surgery, or if it is unfavorable given the patient’s degree of psychiatric illness, caution must be exercised. Patients on MAOIs should not receive meperidine due to the risk of serotonin syndrome related to the concomitant administration of both medications. Enhanced response to vasopressors is also likely, and direct acting agents are preferable over indirect ones. Initially dosing of vasopressors, if required, should be reduced until a patient’s specific dose response is known.

Pain: Patients with chronic pain should continue their home regimen throughout the peri-op period. Long acting pain medications should be taken on the morning of surgery, including mixed opioid agonist-antagonist prescriptions. The expectation that these individuals will have an increased opioid requirement around the time of surgery should be made clear to the patient as well as care providers. If the patient is unable to take oral medications, their baseline opioid requirements should be supplemented in an intravenous form, as well as an increased dose to manage their post-op pain.

j. How to modify care for patients with known allergies

Patients with known antibiotic allergies should be covered with an appropriate alternative. There are few other modifications necessary in the perioperative period for patients with known allergies, other than avoidance of the specific allergenic agents.

k. Latex allergy – If the patient has a sensitivity to latex (e.g., rash from gloves, underwear, etc.) versus anaphylactic reaction, prepare the operating room with latex-free products.

Health care providers for a patient with known latex sensitivity (i.e., rash with latex contact) should wear non-latex gloves, and operative material should be free of latex. Patients with true anaphylaxis to latex should have the OR prepared latex free, and all latex containing products should be removed from the room. Drugs such as epinephrine, diphenhydramine, and an H2-receptor blocker (e.g., ranitidine) should also be readily available should the patient have an anaphylactic reaction. All medications should be drawn up with the rubber stoppers removed if they contain latex.

l. Does the patient have any antibiotic allergies? Common antibiotic allergies and alternative antibiotics

Patients presenting for elective gall bladder surgery are usually not on antibiotics prior to presenting to the OR. Cefazolin 1 to 2 grams IV is the recommended antibiotic for surgical site infection prophylaxis in these patients. For individuals who are severely penicillin allergic or have documented allergies to cephalosporins, clindamycin in conjunction with either a fluoroquinolone or aminoglycoside is an appropriate alternative.

m. Does the patient have a history of allergy to anesthesia?

Patients with a history of anesthetic allergies should be managed in a similar manner as they would be for any other operative procedure.

Malignant hyperthermia (MH)

Documented

Patients with a documented history of malignant hyperthermia need to be treated with a “clean” technique that involves avoidance of any triggering agents (i.e. all volatile agents and succinylcholine).

Proposed general anesthetic plan: Since the vast majority of patients presenting for cholecystectomy will receive a general anesthetic, appropriate precautions must be taken prior to the patient entering into the operating room. Anesthesia machines should be flushed and prepped for an MH case according to their manufacturer’s guidelines. Vaporizers should be removed from the machine or locked from use so that they are not inadvertently used. Nitrous oxide is the one inhaled anesthetic that is an exception and is safe to use in MH susceptible patients. A total IV anesthetic (TIVA) should be used for maintenance either alone or in conjunction with N2O. If a rapid sequence induction is needed, high dose rocuronium (1.2 mg/kg), remifentanil (3-5 mcg/kg) or a priming dose followed by intubating dose of a non-depolarizing muscle relaxant can all be used as an alternative to succinylcholine to facilitate tracheal intubation.

Ensure MH cart available for any location providing general anesthesia: The MH cart should consist of dantrolene in sufficient quantity (recommendations are at least 36 vials) to rescue a patient from an MH crisis. The initial dose is 2.5 mg/kg, but repeat doses of 1 mg/kg are required in up to 25% of patients due to recrudescence. Sterile water must also be available, as this is the only solution in which dantrolene can be mixed. Other medications such as sodium bicarbonate, dextrose 50% (D50), furosemide, calcium chloride, insulin and glucose should all be available to counteract hyperkalemia, which is a frequent finding in MH.

Family history or risk factors for MH

Patients without a definitive diagnosis of MH but who have a positive family history or risk factors should be treated on an individual basis. Many of these patients will be treated with a non-triggering anesthetic given the availability and ease of doing so. If the decision is made to use a potentially triggering anesthetic, an MH cart should be readily available.

Local anesthetics/muscle relaxants

Most allergies to local anesthetics are not truly allergies at all. However, local anesthetics (LA) can cause a delayed-type hypersensitivity reaction (Type IV) and have rarely been documented to also cause Type I IgE mediated reactions. Preservatives found in some local anesthetics have also been linked to allergic reactions that were attributed to the LA itself. In patients with a Type IV reaction, an alternative class of LAs can be chosen (e.g. an amide rather than an ester). In the rare case of a true Type I reaction, local anesthetics are best avoided altogether.

Muscle relaxants are the culprit in sixty to seventy percent of the cases of anaphylaxis associated with anesthesia. Patients who are suspected of having had an allergic reaction under anesthesia should be seen by an allergist and tested prior to undergoing a subsequent anesthetic. If testing is unavailable, an alternative class of muscle relaxants should be used (i.e. a benzylisoquinoline rather than a steroidal or vice versa), although cross-reactivity is possible.

5. What laboratory tests should be obtained and has everything been reviewed?

No specific laboratory test needs to be obtained for a patient undergoing an elective laparoscopic cholecystectomy, unless these are needed, based on the patient’s comorbidities, or suggested, based on the patient’s history. Likewise, an ECG is only required for elderly patients and those with a history concerning for cardiac disease. For non-elective cases, laboratory tests such as a CBC, chemistry and hepatic panel should be obtained based upon the patient’s degree of illness.

The most commonly seen abnormalities in patients presenting for cholecystectomy are abnormalities in liver studies. In ill patients presenting for urgent surgery, an elevation in the white blood cell count may be seen due to inflammation and/or infection, and coagulation disturbances may also be present.

Hemoglobin levels: Most individuals presenting for cholecystectomy will have a normal blood count. It is not necessary to obtain a hemoglobin count prior to a laparoscopic cholecystectomy given the minimal blood loss associated with the procedure. However, it is prudent to obtain an initial hemoglobin count prior to an open cholecystectomy given the increased blood loss seen in an open versus laparoscopic case.

Electrolytes: A chemistry panel should be obtained for patients presenting for urgent cholecystectomy, especially if they have been acutely ill prior to presentation. Poor oral intake and vomiting may cause electrolyte disturbances, which are ideally documented and corrected prior to surgery. In patients who are severely ill, metabolic disturbances due to SIRS or sepsis may cause severe electrolyte derangements potentially leading to cardiac dysrhythmias.

Coagulation panel: A coagulation profile including a platelet count should be obtained if a neuraxial anesthetic is being considered. It is also reasonable to obtain coagulations studies if the patient has altered hepatic synthetic function as a result of their underlying disease.

Imaging: Most patients presenting for cholecystectomy will have some form of imaging performed to evaluate their biliary disease. For most patients, a right upper quadrant ultrasound will have been obtained, but some patients will have undergone a CT scan. It is helpful to review any radiologic imaging prior to surgery in order to better understand the intended operative procedure. Other imaging such as a chest x-ray or stress test should only be obtained if clinically warranted based upon the patient’s comorbidities and using established recommendations such as the ACC/AHA guidelines.

Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?

Almost all patients presenting for cholecystectomy, whether laparoscopic or open, are best served with a general anesthetic. If there is a high likelihood of an open procedure, consideration should be given to placing an epidural catheter for improved postoperative analgesia.

Patients are positioned supine on the operating table, and depending on surgeon preference, one or both of the arms may be tucked at the sides or extended out. For a laparoscopic procedure, the patient will often be placed into reverse Trendelenburg after abdominal insufflation to facilitate surgical exposure.

a. Regional anesthesia

Regional anesthesia is almost exclusively used as an adjunct to general anesthesia for open cholecystectomy, rather than as a primary anesthetic. Due to the necessary abdominal insufflation for laparoscopic surgery, regional anesthesia as the sole anesthetic is poorly tolerated from a respiratory standpoint in awake patients. Although a spinal or epidural anesthetic is possible for open procedures, it is not well suited due to the upper abdominal visceral stimulation and retraction necessary for this surgery.

Neuraxial

An epidural catheter with a combination of opioid and local anesthetic provides improved analgesia for patients who undergo open cholecystectomy versus parenteral opioids. There is also data to support improved respiratory mechanics postoperatively. It is possible to perform either a laparoscopic or open cholecystectomy using an epidural or spinal as the primary anesthetic, however, this is generally not well tolerated for the reasons mentioned above.
Drawbacks: Some patients presenting for cholecystectomy will be acutely, systemically ill, and it is probably best to avoid placing an indwelling catheter in such patients. Additionally, coagulation abnormalities due to hepatic dysfunction and systemic illness may preclude the placement of a neuraxial anesthetic.
Issues: In current surgical practice, less than 10% of patients undergoing cholecystectomy will have an open procedure. Many of the patients who undergo an open approach will be unplanned, i.e. laparoscopic converted to open. Therefore, the vast majority of patients having their gall bladder removed electively will not benefit from a neuraxial technique. For the minority of patients who will undergo a scheduled open cholecystectomy, consideration should be given to offering an indwelling epidural catheter if the patient is an appropriate candidate.
Peripheral nerve block

A paravertebral block can be used for postoperative analgesia in patients who have undergone an open cholecystectomy. One of the main advantages of paravertebral blocks over a neuraxial technique is the ability to place a paravertebral block in patients who may have coagulation disturbances that would otherwise preclude a regional anesthetic.

Drawbacks: Although a paravertebral catheter can be left in place, the majority of these blocks are performed as single injections, and therefore are disadvantageous compared to a neuraxial technique given their finite duration of action compared with an indwelling catheter. Additionally, although a single paravertebral injection can spread cephalad and caudad, the range of dermatomal coverage is likely to be less than what can be achieved with an epidural catheter. As a result, several injections are often required to achieve optimal analgesia.

Issues: Peripheral nerve blocks are rarely necessary in patients undergoing laparoscopic cholecystectomy and are therefore almost exclusively limited to the minority of patients who will undergo an open procedure. In general, they are of limited value given the relatively short duration of action of a single injection technique. Additionally, most anesthesiologists are more comfortable with neuraxial techniques over regional procedures, and practitioner experience will therefore limit their use.

b. General anesthesia

Benefits: General anesthesia (GA) is almost exclusively the primary anesthetic of choice for patients undergoing either a laparoscopic or open cholecystectomy. This method carries a long-standing history of reliability and safety and is therefore preferred by most providers and patients. GA for gall bladder removal almost invariably involves endotracheal intubation. This allows for controlled ventilation, which is particularly relevant for laparoscopic procedures in which abdominal insufflation with carbon dioxide necessitates increased minute ventilation in order to eliminate absorbed CO2. The use of muscle relaxation is also strongly preferable for both laparoscopic and open cases in order to optimize surgical exposure. Lastly, patients undergoing an intra-operative cholangiogram will often receive an IV dose of glucagon to relax the sphincter of Oddi. Glucagon can cause significant nausea in an awake patient but is well tolerated in those under GA.

Drawbacks: General anesthesia for any procedure carries inherent risks that can potentially be avoided with alternative techniques. Hemodynamic perturbations, primarily during induction and emergence may place cardiac patients at risk. Pulmonary function is altered as a result of certain drugs administered for GA as well as mechanical ventilation, which may increase risk for patients with underlying lung disease. However, it is important to note that the dermatomal level needed to achieve surgical anesthesia using a neuraxial technique will also compromise respiratory function.

Airway concerns: As mentioned previously, the vast majority of patients who undergo GA will be intubated and mechanically ventilated. The risk of aspiration is increased in acutely ill patients who may not be NPO and also have delayed gastric emptying due to pain and receiving opioids. Mechanical obstruction due to gallstone ileus should also prompt concern for an increased risk of aspiration upon induction and emergence. In obstructed patients or those who are actively vomiting, placing an NGT prior to induction should be considered. A nonparticulate antacid can be given prior to induction to increase gastric pH should regurgitation and pulmonary aspiration occur.

c. Monitored anesthesia care (MAC)

Benefits: MAC is only appropriate for patients who are undergoing endoscopic or percutaneous drainage procedures, or as an adjunct to regional anesthesia.

Drawbacks: MAC cannot be used as a sole anesthetic for either an open or a laparoscopic procedure. It should also be used with caution in those who are acutely ill due to the risk of aspiration in patients with a depressed level of consciousness.

6. What is the author's preferred method of anesthesia technique and why?

What prophylactic antibiotics should be administered? Cefazolin is the preferred prophylactic antibiotic for nonallergic patients. For patients with beta-lactam allergies, clindamycin or vancomycin are acceptable alternatives.
What do I need to know about the surgical technique to optimize my anesthetic care? Knowledge of the intended surgical procedure (laparoscopic vs. open) as well as the degree of technical difficulty expected are important factors to discuss prior to surgery. The acuity of the procedure and patient’s surgical history may help predict the likelihood of conversion to an open procedure. If a laparoscopic procedure is planned, it is helpful to know whether the surgeon will be using an open technique to gain access to the peritoneal cavity prior to insufflation or a “blind” technique using a Veress needle. If a Veress needle is used, the anesthetist must monitor during insufflation for aberrant needle placement. Cases of intravascular, both arterial and venous, placement have been documented and place a patient at risk for CO2 embolism. Visceral injury is also possible, although unlikely to cause acute physiologic compromise. Subcutaneous insufflation can also occur if the needle is not placed within the peritoneal cavity. If this is not recognized quickly, extensive subcutaneous emphysema can occur leading to prolonged uptake of CO2 and the necessity for an increased minute ventilation to compensate. Upon abdominal insufflation and peritoneal stretching, bradycardia, asystole and other brady-arrhythmias may be seen and should be closely watched for. After successful peritoneal insufflation, additional trochars are then placed and the patient is positioned in reverse Trendelenberg. This position as well as insufflation can lead to hypotension in volume depleted or elderly patients. A surgical dissection is then done to isolate the cystic artery and duct, which are ligated prior to removal of the gall bladder from the liver bed. If an intraoperative cholangiogram or common bile duct exploration is planned, it is performed prior to removal of the gall bladder from the liver. Glucagon is often given for cholangiograms to facilitate dilation of the sphincter of Oddi. Tachycardia as well as hypo- or hypertension can be seen following its administration, although in the author’s personal experience, this is quite rare. Once the gall bladder has been removed from the liver bed, it is then removed through the largest abdominal port and hemostasis is achieved.
What can I do intraoperatively to assist the surgeon and optimize patient care? Adequate neuromuscular blockade will greatly facilitate both an open and laparoscopic cholecystectomy. For both procedures, the surgeon will often request that a gastric tube (either naso- or oral depending on the surgical plan) be placed to decompress the stomach and optimize exposure.
What are the most common intraoperative complications and how can they be avoided/treated? Hemodynamic changes with peritoneal insufflation, largely in the form of arrhythmias, are some of the most common and serious complications that can occur. Close monitoring of the ECG is appropriate at this time and appropriate pharmacologic intervention should be readily available if an arrhythmia does occur. Hypotension can also be seen and should be monitored closely, especially in patients with underlying cardiac disease.

Cardiac complications: Intraoperative cardiac complications should be closely monitored for particularly during induction, emergence and insufflation. Laparoscopy will increase the SVR and potentially compromise patients with limited cardiac reserve. Either increased or decreased venous return can be seen depending on volume status, possibly leading to hypotension. Blood loss is increased during open cholecystectomy and should be documented closely, particularly in those with known underlying cardiac disease.
Pulmonary: Both neuraxial and general anesthesia compromise pulmonary function postoperatively and predispose patients to pulmonary complications. Intraoperatively, appropriate minute ventilation must be maintained during laparoscopy so that CO2 retention does not occur. This can occasionally become quite challenging in patients with significant preexisting pulmonary disease. Laparotomy is an alternative, and sometimes surgically necessary, although increased pain and recovery time increase the incidence of pulmonary complications over those undergoing laparoscopic surgery.

a. Neurologic:

There are no specific neurologic sequelae associated with cholecystectomy.

b. If the patient is intubated, are there any special criteria for extubation?

Almost all elective surgical patients will be extubated at the end of surgery. One notable exception is if significant subcutaneous emphysema is present making extubation unsafe due to anatomic distortion of the airway or if elevated minute ventilation is necessary for CO2 elimination. Urgent surgical patients who are systemically ill may need to remain intubated postoperatively, particularly if significant metabolic derangements exist.

c. Postoperative management

What analgesic modalities can I implement? Parenteral opioids and NSAIDs can be used intra-operatively for patients undergoing laparoscopic cholecystectomy. Most elective surgical patients will be discharged home the same following day on oral opioids. For open surgical patients, an indwelling epidural catheter improves patient analgesia and decreases pain scores. If a neuraxial approach is not possible, parenteral opioids are almost universally needed until resumption of oral intake, at which time patients can be switched to oral medications. Intra-operative adjuncts such as NSAIDs, NMDA receptor blockers, alpha-2 agonists, gabapentin, local anesthetics and acetaminophen should be considered for open surgical patients who are not candidates for a neuraxial anesthetic.
What level bed acuity is appropriate? For most patients, a standard postoperative ward bed is appropriate. A monitored bed is typically only required for patients with significant underlying medical disease.
What are common postoperative complications and ways to prevent and treat them? Patients who undergo open surgery are at increased risk for postoperatively complications than their laparoscopic counterparts. Mechanical and chemical thromboprophylaxis should be strongly considered after open surgery, with careful consideration given to anticoagulant choices if a neuraxial technique is chosen. Incentive spirometry and early ambulation may help to minimize pulmonary complications postoperatively. Adequate analgesia is also essential to help eliminate pain as a cause of post-op delirium.

What's the Evidence?

Fleisher, LA, Beckman, JA, Brown, KA, Calkins, H, Chaikof, E, Fleischmann, KE, Freeman, WK, Froehlich, JB, Kasper, EK, Kersten, JR, Riegl, B, Robb, JF. “ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery)”. Circulation. vol. 116. 2007. pp. 1971-96.

Loper, KA, Ready, LB, Nessly, M, Rapp, SE. “Epidural morphine provides greater pain relief than patient-controlled intravenous morphine following cholecystectomy”. Anesth Analg. vol. 69. 1989. pp. 826-8.

Bisgaard, T. “Analgesic treatment after laparoscopic cholecystectomy: A critical assessment of the evidence”. Anesthesiology. vol. 104. 2006. pp. 835-46.

Putensen-Himmer, G. “Comparison of post-operative respiratory function after laparoscopic or open laparotomy for cholecystectomy”. Anesthesiology. vol. 77. 1992. pp. 675-80.

Cunningham, AJ, Brull, SJ. “Laparoscopic cholecystectomy: anesthetic implications”. Anesth Analg. vol. 76. 1993. pp. 1120-33.

Joris, BL. “Hemodynamic changes during cholecystectomy”. Anesth Analg. vol. 76. 1993. pp. 1067-71.

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