What is the recommended anesthesia plan for a 38-year-old female with migraine, endometriosis, and hypothyroidism undergoing total laparoscopic hysterectomy and bilateral salpingectomy?

Anesthesia Plan for Total Laparoscopic Hysterectomy with Bilateral Salpingectomy

For a 38-year-old female with migraine, endometriosis, and hypothyroidism undergoing laparoscopic hysterectomy, a multimodal anesthetic approach using either sevoflurane-based balanced anesthesia or TIVA is recommended, with TIVA being preferable for patients with migraine history to reduce PONV risk. 1

Patient Presentation

• 38-year-old female
• Procedure: Total laparoscopic hysterectomy and bilateral salpingectomy
• Medical history: Migraine, endometriosis, hypothyroidism
• All preoperative bloodwork normal
• ASA II

Preoperative Management

• Verify thyroid medication has been taken on morning of surgery
• Assess airway parameters (Mallampati score, neck circumference, thyromental distance)
• Administer preoperative antiemetics due to high PONV risk:
  • Dexamethasone 8 mg IV (after induction)
  • Ondansetron 4 mg IV (prior to emergence)

Induction Protocol

1. Preoxygenation with 100% oxygen for 3 minutes
2. Induction medications:
   • Propofol 2-2.5 mg/kg IV (140-175 mg for 70 kg patient)
   • Fentanyl 1-2 mcg/kg IV (70-140 mcg for 70 kg patient)
   • Rocuronium 0.6 mg/kg IV (42 mg for 70 kg patient)
3. Intubation with appropriate-sized endotracheal tube (typically 7.0-7.5 mm)
4. Consider videolaryngoscopy for optimal visualization

Maintenance Options

Option 1: Sevoflurane-Based Balanced Anesthesia

• Sevoflurane 1-2% (0.8-1.0 MAC) in oxygen/air mixture (FiO2 0.5)
• Supplemental remifentanil infusion 0.05-0.2 mcg/kg/min
• Rocuronium maintenance doses of 10 mg as needed to maintain deep neuromuscular blockade
• BIS monitoring target 40-60

Option 2: TIVA Protocol (Preferred for migraine history)

• Propofol infusion 100-150 mcg/kg/min (target plasma concentration 3-6 mcg/ml)
• Remifentanil infusion 0.1-0.3 mcg/kg/min
• Rocuronium maintenance doses of 10 mg as needed
• BIS monitoring target 40-60

Ventilation Parameters

• Pressure-controlled ventilation
• Tidal volume 6-8 mL/kg ideal body weight
• PEEP 5-8 cmH2O
• Respiratory rate adjusted to maintain ETCO2 35-40 mmHg
• Periodic recruitment maneuvers during Trendelenburg position

Intraoperative Fluid Management

• Crystalloid solution (Lactated Ringer's) 4-6 mL/kg/hr
• Goal-directed fluid therapy using minimally invasive cardiac output monitoring
• Maintain mean arterial pressure within 20% of baseline
• Use vasopressors (phenylephrine 50-100 mcg boluses) to maintain blood pressure if needed

Multimodal Analgesia Plan

1. Prior to incision:

   • Dexamethasone 8 mg IV (also serves as antiemetic)
   • Ketorolac 30 mg IV (if no contraindications)
   • Acetaminophen 1000 mg IV

2. Regional analgesia options:

   • Ultrasound-guided bilateral TAP blocks with 20 mL 0.25% bupivacaine per side
   • Local anesthetic wound infiltration at port sites (20 mL 0.5% bupivacaine)

3. Intraoperative opioid management:

   • Hydromorphone 0.5-1 mg IV prior to emergence
   • Or fentanyl 50-100 mcg IV prior to emergence

Emergence Plan

1. Discontinue anesthetic agents after fascial closure
2. Reverse neuromuscular blockade:
   • Sugammadex 2-4 mg/kg IV based on TOF monitoring
3. Ensure full reversal with TOF ratio > 0.9 before extubation
4. Extubate when fully awake with adequate spontaneous ventilation

PONV Prevention and Management

• High risk patient (female, non-smoker, history of migraine)
• Multimodal prophylaxis:
  • Dexamethasone 8 mg IV (given after induction)
  • Ondansetron 4 mg IV (prior to emergence)
  • Consider scopolamine patch if severe PONV history
• Rescue antiemetics:
  • Promethazine 12.5 mg IV or
  • Metoclopramide 10 mg IV

Postoperative Analgesia

1. Continue multimodal approach:

   • Acetaminophen 1000 mg IV/PO q6h
   • Ketorolac 30 mg IV q6h (max 120 mg/24h) or ibuprofen 600 mg PO q6h
   • Tramadol 50-100 mg IV/PO q6h PRN for moderate pain
   • Hydromorphone 0.5-1 mg IV q4h PRN for severe pain

2. Consider IV lidocaine infusion (1-2 mg/kg/hr) if severe pain, especially with history of endometriosis

Special Considerations

• Migraine history: TIVA may be preferable over inhalational anesthetics to reduce PONV risk 1, 2
• Hypothyroidism: Ensure adequate perioperative thyroid replacement; patients with well-controlled hypothyroidism generally tolerate anesthesia well 3
• Endometriosis: May require more aggressive pain management; consider TAP blocks and multimodal analgesia 1

Monitoring

• Standard ASA monitors (ECG, NIBP, SpO2, ETCO2, temperature)
• BIS monitoring (target 40-60)
• Neuromuscular monitoring with train-of-four (TOF)
• Consider arterial line if significant comorbidities present

Potential Complications and Management

• Pneumoperitoneum-related hemodynamic changes: Treat with vasopressors and adequate fluid management
• Positioning-related issues: Ensure proper padding of pressure points during steep Trendelenburg
• PONV: Use multimodal prophylaxis and early rescue treatment
• Pain: Aggressive multimodal approach with regional techniques

This anesthesia plan incorporates evidence-based approaches for laparoscopic gynecological surgery with specific considerations for the patient's comorbidities, focusing on optimal pain management and PONV prevention to improve recovery outcomes.