Je continue ma série de fiches de cuisine avec la description de ma pratique de l’induction anesthésique pour de la chirurgie viscérale. Ici la description de la majorité de mes inductions pour un patient « classique » en chirurgie digestive majeure.
Analgésie/Anesthésie loco-régionale
Rachianalgésie
Sur le plan théorique, je limiterais les indications de rachianalgésie aux patients pour lesquels le rapport bénéfice/risque pour bénéficier d’une analgésie péridurale n’est pas bon et/ou en cas d’échec de pose de péridurale. La chirurgie hépatique lourde avec des fluctuations franches du bilan de coagulation en post-opératoire incite aussi à préférer la rachi à la péri où le risque d’hématome périmédullaire serait trop grand.
Dans la rachi, je mets facilement entre 100 et 200 µg (mcg) de morphine assez régulièrement associée à 1 µg/kg de clonidine. J’évalue le « risque » de la clonidine en fonction du risque hémorragique et/ou de la précarité de l’état cardiovasculaire du patient.
Analgésie péridurale
Dans un monde idéal où la pose de péridurale serait très bien organisée et routinière, je pense que beaucoup de patients de chirurgie digestive pourraient en bénéficier. Ceci est mon impression liée au fait de voir un patient beaucoup plus confortable en post-opératoire avec une péridurale. La littérature médicale, plus rigoureuse, rapporte moins d’enthousiasme, moins d’amélioration du pronostic sur des marqueurs « lourds » comme la morbi-mortalité. L’utilisation de la péridurale sera différente selon que la chirurgie est à haut risque d’être instable (oesophagectomie) ou plus routinière (résection digestive par laparotomie). Dans la majorité des cas, je mets 5 µg de sufentanil en péridural dès le début de l’intervention. Si le patient ou la chirurgie sont simples, je démarre de façon concomittante à l’induction intraveineuse une SAP de naropéine à 2mg/ml entre 6 et 10 ml/h. Pour une oesophagectomie selon Lewis-Santy, je suis plus prudent, je démarre de la naropéine à 1 mg/ml entre 6 et 10ml/h pendant le temps abdominal et je la mets en suspens pendant le temps thoracique.
TAP block
Le TAP block est une alternative séduisante aux techniques périmédullaires. La possibilité de laisser un cathéter en place permet de poursuivre l’analgésie en post-opératoire. Lorsqu’un TAP block est envisagé il est préférable de le réaliser avant l’incision chirurgicale pour que le patient en bénéficie le plus.
L’induction intra-veineuse
Dès la perfusion posée, je lance le cristalloïde en débit libre pour compenser la déshydratation du jeûne.
Je commence par l’antibioprophylaxie pendant la préoxygénation, avant de faire n’importe quelle autre drogue anesthésique. Si le patient fait malheureusement une anaphylaxie grave, je suis certain que le fait d’avoir injecté des drogues anesthésiques sympatholytiques aggrave la situation. Je ne comprends pas l’argument « rassurant » déjà entendu comme quoi il vaut mieux faire une allergie grave en étant déjà intubé. Je ne pense pas que lors d’un choc anaphylactique qui se déroule devant nos yeux chez un patient oxygéné on n’ait pas le temps ou la compétence pour réussir à le ventiler et/ou à l’intuber.
Je ne tente pas le diable : si le patient rapporte une allergie à la pénicilline, je n’utilise ni péni, ni céphalosporine.
J’utilise très rarement le midazolam. Je trouve que la prémédication intraveineuse au midazolam complique les gestes d’ALR plus qu’il ne les facilite par la désinhibition ou la perte de tonus engendré. Je l’utilise à petite dose si je suis devant une patiente à très haut risque de NVPO.
Ensuite vient le temps de la prévention des NVPO, j’utilise préférentiellement 4 mg de dexaméthasone à l’induction. Il n’y a que des arguments indirects, mais je préfère réserver le dropéridol pour la fin de l’intervention dans notre contexte d’intervention plutôt longue.
J’enchaîne avec le morphinique. La chirurgie dans mon secteur relève plutôt du sufentanil, que j’injecte à dose modérée, 0,1 à 0,15 µg/kg. Petite dose car bien souvent on attend un moment avant l’incision (magie du CHU) et que les conditions d’intubations seront surtout facilitées par l’utilisation d’un curare.
Puis vient immédiatement le temps d’un peu de propofol. Je n’attends pas l’imprégnation par le cerveau et la moelle par le sufentanil puisque les conditions d’intubation seront assurées par le curare et le propofol. Pas besoin de faire vivre la sensations ébrieuse du sufentanil au patient (non ça n’est pas toujours vécu comme un shoot relaxant). Je mets toujours entre 10 et 30 mg de lidocaïne dans le propofol pour tamponner son pH et limiter les douleurs à l’injection. A ce stade j’injecte entre 30 et 50 mg de propofol pour « déconnecter le patient ».
Ensuite, j’injecte de la kétamine entre 0,25 mg/kg et 0,5 mg/kg pour prévenir l’hyperalgésie. Avoir injecté le propofol avant permet de limiter les sensations désagréables de décorporation et/ou des effets psycho-dysleptiques. Chez une personne âgée très fragile, je réfléchis à deux fois avant d’utiliser la kétamine à visée anti-hyperalgésique. Si je choisis d’administrer de la kétamine à une personne âgée à risque de troubles cognitifs post-opératoires. Je la mets plutôt à couler doucement dans la perfusion de base car des travaux ont montré que les troubles psycho-dysleptiques étaient correlés au pic de concentration plasmatique (moins élevée avec une administration « lente » dans la perfusion).
Si le patient ne bénéficie pas d’une analgésie périmédullaire. J’utilise assez volontiers la lidocaïne à 1,5 mk/kg pour ses vertus anti-inflammatoire et anti-hyperalgésiante. Je l’injecte toujours doucement (comme les autres drogues bien sûr mais encore plus précautionneusement). La lidocaïne permet d’utiliser moins de morphiniques en périopératoire et permet vraisemblablement une réhabilitation plus rapide (reprise du transit notamment). Notez bien que je fais la lidocaïne après avoir fait un peu de propofol, j’espère ainsi protéger le patient du risque de convulsion (plutôt théorique à 1,5 mg/kg injecté doucement).
Je continue l’approfondissement de l’hypnose avec le propofol, bien guidé par la clinique et des systèmes de surveillance comme le BIS ou l’entropie. Je fais particulièrement attention chez les sujets très âgés. On a rarement besoin de plus de 1 mg/kg dans cette population.
On vérifie la ventilation au masque sauf contexte particulier. On lance l’étalonnage du moniteur de curarisation. On utilise régulièrement l’atracurium et le rocuronium. Je préfère réserver le rocuronium aux patients qui sont le plus à risque d’inhaler (avec une posologie à 1 mg/kg) et/ou à ceux qui bénéficieront le plus d’une réversion des curares par sugammadex (très fragiles, obèses, NVPO +++). En effet je pense que le risque d’histamino-libération supérieur avec le rocuronium justifie qu’on pèse le pour et le contre avant de l’utiliser même si l’on est beaucoup plus tenté de l’utiliser depuis l’utilisation courante du sugammadex. Quitte à utiliser un curare, on attend qu’il fasse bien effet pour limiter les lésions laryngées. Toujours sur cette même idée je pense qu’il n’y a aucune justification en terme de physiologie, de ventilation ou que sais-je pour utiliser une sonde > 7,5 chez les hommes et > 7 chez les femmes. Une fois l’intubation réalisée, on vérifie la pression du ballonnet pour s’assurer qu’on n’écrabouille pas la muqueuse sous-glottique.
Si j’ai affaire à un patient très neurotonique et/ou à haut risque de chronicisation de sa douleur post-opératoire et/ou de NVPO, j’utilise souvent la clonidine. Je l’administre dans la perfusion de départ à une posologie oscillant entre 1 et 4 µg/kg. Si après ce premier bolus le patient reste hypertendu ou semble inconfortable, j’essaye des boli en IVD de 15 à 30 µg de clonidine.
UPDATE septembre 2013, la clonidine n’est pas simple à manier… plus je l’utilise plus je trouve que le moyen le plus sécurisant est de l’utiliser en SAP, SANS BOLUS, le patient montre des signes d’imprégnation au bout de 1 microgramme/kg. Classiquement je fais une SAP de 600 microgrammes dans 20 ml, je mets le PSE vitesse 2 ml/h pendant une heure et je regarde comment réagit le patient et j’adapte. Chez les patients âgés, je diminue la posologie par deux.
Avec un degré de preuve peu élevé, j’utilise aussi souvent du sulfate de magnésium, 3g en IVL un peu après l’induction, au moment du démarrage de la chirurgie. Le sulfate de magnésium pourrait être intéressant pour relâcher le muscle lisse bronchique chez les BPCO, pour prévenir les arythmies supra-ventriculaires dans les chirurgies à risque (thoracotomie) et peut jouer un rôle dans la lutte contre la douleur et l’hyperalgésie du fait de son rôle de cofacteur du canal NDMA.
Lexique des abréviations :
TAP = transversus abdominis plane : plan du muscle transverse.
ALR = anesthésie loco-régionale
NVPO = nausées ou vomissements post-opératoires
BIS (pour ce texte) : Bispectral Index
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23 réponses sur « Ma séquence d’induction en chirurgie viscérale »
Pourquoi du Sufenta à l’induction ???
Si je comprends bien, il s’agit d’une dose de 5 à 10 µg. Tu dis bien qu’il ne te sers pas pour modérer la réponse sympathique à l’intubation … alors why ?
Nos amis anglais ont fait de l’anesthésie sans morphiniques pendant des années. Nos pères (ceux à qui on doit l’utilisation de morphiniques en perop) avaient dés le début remarqué la tolérance aiguë aux morphiniques, en particulier ceux de la famille des piperidines (fentanyl, alfentanil, sufentanil, remifentanil). Je renvoie aux travaux de Mundeleer et De Castro. Ils avaient aussi remarqué que ces molécules procurent une grande stabilité hémodynamique et une suppression très efficace des réactions hyperadrénergiques impossible d’obtenir à l’époque avec les barbituriques ou les gaz anesthésiques. Qu’est-ce qui a changé ? Nous avons à notre disposition des anesthésiques généraux puissants, non toxiques et peu cardiodépresseurs. Nos patients sont mieux préparés : meilleure évaluation, revascularisation coronaire, stabilisation des affections pulmonaires, quasi disparition des séquelle de BK, valvulopathies moins endémiques (RAA) etc … Est-il temps de repenser à la place des agonistes morphiniques en perop ?
On sait aujourd’hui que les récepteurs morphiniques sont un peu partout dans notre corps et que leur effet analgésique n’est pas le seul. Pensons aux effets immunitaires si néfastes en cas de chirurgie ontologique !
Je sais que l’injection de 10 µg de Sufenta a un effet sur plein de systèmes … Moi, j’évite et je préfère donner un peu de façon très ciblée. Par contre, par voie périmédullaire, j’en donne un peu plus.
Enfin, je remarque cette habitude un peu triste en cas de chirurgie « difficile » : pas d’anesthésiques locaux dans la péri !
Je n’arrive pas à comprendre cette attitude. Le blocage des afférences sympathiques de la région opérée diminue le saignement, notamment. On redoute le saignement … Pourquoi ne pas mettre le patient dans l’état où il saignera moins. Alors que la péri permettrait d’avoir « un coup d’avance », on n’en profite pas. Bon d’accord, on ne peut pas être toujours un grand joueur d’échec mais un peu de stratégie ne me semble pas si bête.
ah chouette un peu de provoc’ belge 🙂
Pourquoi encore du suf à l’induction ?
* je n’ai pas écrit ce que tu me prêtes là : « Tu dis bien qu’il ne te sers pas pour modérer la réponse sympathique à l’intubation » Je causais de la synergie morphinique/hypnotique pour avoir de bonnes conditions d’intubation. J’en ai pas besoin car il y a un curare, par contre limiter la réponse sympathique à l’intubation ne me parait pas être une mauvaise idée
* on mobilise quand même le patient, on lui remet des cathéters dans le kiki, les bras, le nez, etc.
* parfois on arrive à inciser dans un délai raisonnable par rapport à l’induction
* si je ne mets pas un peu de suf à l’induction, le patient va récolter 25 ou 30 µg lorsque je passerai dans l’autre salle 😉
* si je n’en mets pas à l’induction, quelqu’un risquerait d’appeler le
psy de liaison dans mon dos et de demander qu’on me colle en HDT
Et toi tu ne mets plus du tout de sufentanil à l’induction ?
Le discours sur les effets immunitaires m’interpellent et ce discours est utile pour faire réfléchir sur l’utilisation des opiacés.
La péri c’est bien, tu sais que ça me tient à coeur mais il existe des complications sévères qui aurait pu ne pas arriver avec une autre stratégie (j’ai un mauvais souvenir d’une méningite en uro…) Le bloc paravertébral que je ne maitrise fait sans doute très bien pour une thoracotomie (cf biblio), la solution est plus par là pour moi aujourd’hui.
De plus lors d’une oesophagectomie selon Lewis-Santy, lorsque nos confrères chirurgiens appuient sur le coeur, la veine cave et/ou l’aorte je me dis que ça n’est pas plus mal de gêner encore le retour veineux avec le bloc sympathique de la péri. La ça n’est pas une histoire de saignement, c’est un problème mécanique de tuyauterie.
Antibiotiques au moment de la pose de la vvp pour respecter le délai d’action. La lidocaine dans une autre seringue et faire de la vraie alriv de la veine…
OK pour antibiotique car dans les recos c’est bien écrit de séparer de plusieurs minutes l’antibio de la séquence d’induction. Après concernant le délai d’action, vu notre délai moyen entre induction et incision dans le service…
Pour la notion d’ALRIV, ok ça marche (cf méta-analyse BMJ) mais en pratique pour mettre tout le temps de la lido dans le propofol depuis environ 3 ans je constate vraiment que les patients qui ont mal à l’injection ne constitue qu’un infime pourcentage comparé à sans lido. Ca fonctionne vraiment. Fais toi une semaine avec lido et une semaine sans lido tu verras par toi même
Ce truc du pH du propofol à tamponner (cf essai où il y a avait un groupe acide HCl qui tamponne le propofol) par la lido me séduit plus que « l’anesthésie d’une veine », j’ai du mal à y croire…
Pitié pour les mal-comprenants !! ou bien est-ce un blog réservé aux AR ?
que de sigles…: TAP, SAP, NVPO, ALRIV…
on arrive à en deviner certains, mais pour d’autres ?
L’intérêt de ce blog pour moi est l’accès au raisonnement spécifique de l’anesthésiste-réanimateur. Laissez les ignares en profiter un peu, siouplaît !
(un médecin d’un autre horizon)
merci pour cette importante remarque, j’ai rajouté une liste des abréviations en fin d’article
Je souhaite effectivement que tout à chacun puisse consulter ce site, c’est tout l’intérêt de l’Internet et du blogging. Il est vrai que j’aborde une prise en charge hautement spécifique et je me suis laissé emporter dans du jargon anesthésique.
Si vous avez des questions spécifiques, je serai heureux d’y répondre
Bonjour Nfkb,
J’ai une question spécifique à propos de chirurgie viscérale et d’anesthésie loco-régionale (je suis patient) : je dois subir une ablation de la vésicule biliaire (à cause de calculs) et ne peux me résoudre à l’anesthésie générale. Désolé, j’en ai très honte, mais non possum. Et votre billet du 1er juin 2016 à ce sujet ne m’a malheureusement pas fait changer d’avis. Existe-t-il des lieux où cette intervention pourrait être effectuée sans AG, par exemple sous ALR seule (via une laparotomie) ? Merci.
Bonjour,
je suis sensible à votre message.
Néanmoins, je n’ai jamais vu ou entendu parler de cholecystectomie sous ALR seule. Je vous avoue que je ne sais même pas dire si c’est possible. J’ai des idées mais c’est de l’imagination, pas de la Médecine basée sur des preuves.
Avez vous rencontré des médecins anesthésistes de l’équipe du chirurgien qui a posé l’indication ?
Merci de votre réponse.
Oui, au départ le chirurgien était d’accord, et l’anesthésiste aussi ! Mais ce dernier s’est désisté (apparemment suite à des critiques de ses collègues), puis le chirurgien est parti à la retraite (non, ce n’est pas un gag). Depuis, j’ai frappé à d’autres portes, mais n’ai eu que des refus. Je suis très ennuyé. Il est vrai que la pratique de l’ALR seule semble être une pratique « de pauvre », pas ou peu pratiquée en Occident. Vous semblez d’ailleurs le confirmer. Je n’ai de fait trouvé à ce sujet sur le Net que des documents africains, dont celui-ci, qui rend compte de laparotomies sous rachianesthésie et évoque même des laparoscopies sous rachianesthésie « en démontrant de nombreux avantages de cette dernière » (voir p. 8 de l’Intro ou p. 9 web) : il n’y a pas de lien direct, il faut coller « Cholecystectomie par laparotomie sous costale sous rachianesthesie zghaid » dans Google, puis cliquer à la fin de la première ligne sous la petite flèche PDF. Cela semble démontrer que l’ALR seule serait possible, si j’ai bien compris…
oui je pense que c’est techniquement possible, mais comme toujours en Médecine, on fait bien et en sécurité ce qu’on fait souvent. En tout cas ça me parait cavalier de piquer une rachianesthésie si haut comme décrit dans cette thèse. A la rigueur, j’aurais pensé à une anesthésie péridurale. Plus long à « prendre » mais beaucoup plus safe je pense.
Je note aussi dans le protocole de cette thèse, ils préviennent de pouvoir faire une anesthésie générale si le niveau sensitif n’est pas atteint.
J’imagine que c’est désagréable à entendre mais je trouverais intéressant de travailler sur l’acceptation de l’anesthésie générale. Peut être avec un médecin anesthésiste qui est formée à la communication thérapeutique et/ou l’hypnose.
En effet, votre collègue m’avait parlé d’une péridurale et non d’une RA. Il était également convenu de la transformer en AG au cours de l’opération si vraiment nécessaire. Quoi qu’il en soit, si vous avez des pistes pour trouver le très précieux binôme chirurgien/anesthésiste acceptant d’effectuer cette opération sous ALR seule, je vous remercie d’avance de bien vouloir me les indiquer.
Je travaille également sur l’acceptation de l’AG, comme vous dites. J’ai même pris RDV avec un psy spécialiste en phobies (la semaine prochaine). Je n’y crois guère, mais je veux tout essayer.
Evidemment je suis aussi tout à fait prêt à discuter avec un médecin anesthésiste formé à la communication thérapeutique et/ou l’hypnose. Mais, dans la région où je réside (Lorraine), on ne m’en a pas proposé. Et je n’en connais pas. Là aussi, si vous avez des pistes et des adresses, SVP n’hésitez pas. Je suis prêt à me déplacer n’importe où en France.
Par ailleurs, je me demande aussi s’il existerait des médicaments psychotropes extrêmement puissants, du genre à vous faire monter à l’échafaud le sourire aux lèvres… Et si leur prise serait compatible avec les produits anesthésiants administrés par la suite ?
Ça c’est certain qu’on peut vous donner un sédatif puissant qui puisse vous aider à accepter les choses.
Essayez de trouver un annuaire de médecins pratiquants l’hypnose dans votre région.
S’il existe des sédatifs puissants qui ne sont pas incompatibles avec l’anesthésie, j’en prendrai plusieurs heures ou jours avant. Pouvez-vous m’en citer ?
Pour les médecins pratiquant l’hypnose, selon l’annuaire de l’Institut français d’hypnose, qui semble faire autorité en la matière, il n’y en a pas dans mon département. Mais ce qui m’intéresse surtout, c’est de connaître des hôpitaux ou cliniques connus pour leur accompagnement en matière d’anesthésie. Cela doit certainement exister, et sans doute en avez-vous à tout le moins entendu parler dans votre milieu professionnel ?
Je vous écris. Je parie que j’ai atterri dans votre boîte spam. Regardez et voyez de ce côté la
Pour Pierre T-D : http://www.nfkb0.com/wp-content/uploads/2012/09/ejp211.pdf
On utilise la gabapentine au cas par cas. Il faut aller voir le billet sur la prémédication 🙂
http://www.nfkb0.com/2012/08/10/la-premedication-22/
(et félicitations pour ton Sélection37 !)
Cher Rémi, c’est toujoujours un plaisir de te lire et ton article est très intéressant.
– J’utilise aussi quelques cc de lidocaine dans le propofol (surtout sur les petites voies veineuses et chez les enfants)
– Pour l’antibioprophyllaxie, une récente revue de morbidité-mortalité (RMM) à la maternité a conclu au caractère délètere de la prise en compte d’une « notion d’allergie à la pénicilline » chez une parturiente infectée (antibiothérapie non ciblée / retard de prise en charge). Il y a grosso modo 10% des patients qui se déclare « allergique à la pénicilline » pour environ 1% d’allergie vraie.
Je ne tente pas le diable non plus mais la notion « d’allergie à la pénicilline » doit être argumentée dans le dossier de soins (et/ou d’anesthésie) …. l’oedème de Quincke étant bien plus pertinent que la notion de quelque chose dans la petite enfance (on m’a dit que…). Si l’allergie n’est pas pertinente, je met des céphalosporines sans arrière pensée.
Salut Pierrot,
merci pour ta participation.
Je suis bien d’accord avec toi concernant les « chichis » sur la notion d’allergie à la péni. Mais je trouve alors d’autant plus important de faire l’antibioprophylaxie chez un patient réveillé pour ne pas aggraver l’histaminolibération par la vasodilatation des drogues d’anesthésie justement qu cas où une anaphylaxie se déclarerait.
Tchuss
Comme toi j’aime bien le Mg2SO4,,, mais la dernière fois que je l’ai utilisé c’était pour potentialiser la réplétion potassique IV pendant une réparation d’AAA qui tirait en longueur et vers les 3.0mmol de K.
Résultat : 4h30 à TOF=0 après un 1mg/kg de rocuronium
Racontant l’histoire à mon PUPH celui ci me répond avec un demi sourire : « Mon cher ami, j’ai publié dessus en 1996 (PMID:8652332) mais il n’est jamais inutile que les jeunes fassent leur propres expériences… »
D’ou l’intéret d’avoir une vague idée de l’historique bibliographique du service et de ses patrons….
Pour la xylocaine… Xylocard €xclusiv€m€nt? (on s’est tapé une note de la pharma centrale rappellant que la seule forme de lidocaine autorisée en IV était la 0.5%)
PS ; marrant de tetrouver un ancien pilier d’ecarabin…;-)
Bonjour,
je fais aussi des iono et des GDS sur les blocs longs comme ça. Particulièrement les thoraco pour oesophagectomie ou l’hypokaliémie peut faciliter le passage en FA. Je vise toujours une kaliémie haute chez ces patients, vaut 4,5-5,5 que 3-4
Pour la lido, j’utilise de la 1% pour l’induction, je crois qu’il n’y a qu’une questions d’AMM avec un produit identique, à vérifier avec vos pharma et Aguettant. Pour les SAP per et post-op je prends du XYLOCARD
Apparemment tu as bien travaillé si tu as réussi à t’implanter là où tu es 🙂
[…] de la kétamine. Il n’y a pas d’intérêt à commencer par la kétamine dans sa séquence d’induction. Deuxième détail : j’essaye au maximum de couper la SAP de kétamine avant la fin du bloc, […]
[…] en pratique, je l’utilise souvent à 1,5 mg/kg à l’induction (après avoir fait des petites doses d’hypnotiques et la kétamine qui augmentent le seuil […]