What is the recommended anesthesia plan for a 60-year-old female with a history of Gastroesophageal Reflux Disease (GERD), Hypertension (HTN), hypothyroidism, mood disorder, obesity, and elevated Liver Function Tests (LFTs) undergoing a total laparoscopic hysterectomy?

Anesthesia Plan for Total Laparoscopic Hysterectomy in a 60-Year-Old Female with Multiple Comorbidities

For this 60-year-old female with multiple comorbidities including GERD, HTN, hypothyroidism, mood disorder, obesity, and elevated LFTs, a general endotracheal anesthesia (GETA) with total intravenous anesthesia (TIVA) is strongly recommended over sevoflurane to minimize hepatic impact and optimize hemodynamic stability.

Patient Presentation

• 60-year-old female (79 kg, BMI 32.0)
• Scheduled for total laparoscopic hysterectomy for endometrial hyperplasia/intraepithelial neoplasia
• Significant comorbidities:
  • EtOH use disorder (previously 4 servings/day) with elevated LFTs
  • GERD (on pantoprazole)
  • HTN (on lisinopril)
  • Hypothyroidism (on levothyroxine)
  • Mood disorder (on fluoxetine, pregabalin)
  • Obesity (BMI 32)
  • Suspected OSA (STOP-BANG 5/8)
• Functional capacity >4 METs
• Mallampati 2 with reassuring airway anatomy

Preoperative Management

1. Medications:

   • Continue all home medications except lisinopril (hold on day of surgery) 1
   • Administer preoperative anxiolytic: midazolam 1-2 mg IV (short-acting) 2
   • Antacid prophylaxis: pantoprazole 40 mg IV (already on home regimen) 1

2. Monitoring Setup:

   • Standard ASA monitors
   • Arterial line placement post-induction (right radial) for continuous BP monitoring and blood sampling 1
   • BIS monitoring (target 40-60) due to age >60 and risk of delirium 2
   • Quantitative neuromuscular monitoring (TOF) 2

Induction Plan

1. Pre-oxygenation: 100% O₂ for 3 minutes
2. Rapid sequence induction due to GERD and obesity 2:
   • Fentanyl 100 mcg IV (1.25 mcg/kg)
   • Propofol 160 mg IV (2 mg/kg)
   • Rocuronium 80 mg IV (1 mg/kg) for rapid onset 2
   • Apply cricoid pressure until ETT placement confirmed 2
3. Intubation: 7.0 mm ETT with video laryngoscope

Maintenance Plan

1. TIVA Protocol (preferred over sevoflurane due to elevated LFTs) 1:

   • Propofol infusion 100-150 mcg/kg/min (7.9-11.9 mg/min)
   • Remifentanil infusion 0.1-0.25 mcg/kg/min (7.9-19.8 mcg/min) 3
   • Titrate to maintain BIS 40-60

2. Ventilation Strategy 2:

   • Pressure-controlled ventilation
   • Tidal volume 6-8 mL/kg IBW (approximately 400-450 mL)
   • PEEP 8-10 cmH₂O
   • Respiratory rate 12-14/min, adjusted to maintain ETCO₂ 35-40 mmHg
   • Periodic recruitment maneuvers, especially after pneumoperitoneum and Trendelenburg positioning

3. Hemodynamic Management:

   • Maintain MAP within 20% of baseline 1
   • Treat hypotension with phenylephrine boluses (50-100 mcg) or infusion (0.3-0.5 mcg/kg/min)
   • Target urine output >0.5 mL/kg/hr

4. Fluid Management:

   • Balanced crystalloid solution (Lactated Ringer's) 2
   • Total volume 10-15 mL/kg (approximately 800-1200 mL)

5. PONV Prophylaxis (high risk due to female gender, non-smoker) 2:

   • Dexamethasone 4 mg IV at induction
   • Ondansetron 4 mg IV 30 minutes before end of case
   • Consider aprepitant 40 mg PO preoperatively for additional prophylaxis

Emergence Plan

1. Prior to Emergence:

   • Multimodal analgesia:
     • Acetaminophen 1000 mg IV
     • Ketorolac 30 mg IV (if no contraindications)
     • Local anesthetic infiltration of port sites by surgeon (20 mL of 0.25% bupivacaine)
   • Discontinue remifentanil infusion 5-10 minutes before end of case
   • Reduce propofol infusion rate

2. Neuromuscular Blockade Reversal 2:

   • Monitor TOF ratio at adductor pollicis
   • Administer sugammadex 2-4 mg/kg IV (160-320 mg) based on TOF monitoring 2
   • Ensure TOF ratio >0.9 before extubation

3. Extubation:

   • Extubate when fully awake with return of airway reflexes
   • Perform in semi-sitting position 2
   • Consider insertion of nasopharyngeal airway before emergence due to OSA risk 2

Postoperative Management

1. Pain Management:

   • Continue multimodal approach:
     • Acetaminophen 1000 mg IV/PO q6h
     • Ketorolac 30 mg IV q6h for 24h (if no contraindications)
     • Hydromorphone 0.2-0.4 mg IV PRN for breakthrough pain

2. Monitoring:

   • Extended PACU observation (minimum 3 hours) due to OSA risk 1
   • Continuous pulse oximetry until fully mobile 1
   • Consider CPAP if patient uses it at home 2

3. VTE Prophylaxis:

   • Early mobilization
   • Mechanical prophylaxis (sequential compression devices)
   • Pharmacological prophylaxis with LMWH 1

Special Considerations

1. Liver Function:

   • TIVA preferred over inhalational agents due to elevated LFTs
   • Monitor for signs of hepatic dysfunction postoperatively

2. OSA Management:

   • Careful titration of opioids
   • Maintain head-up position postoperatively
   • Consider CPAP if desaturations occur

3. Potential Complications:

   • Respiratory: Atelectasis, hypoxemia (due to obesity, OSA, and laparoscopy)
   • Cardiovascular: Hemodynamic changes with pneumoperitoneum and positioning
   • Surgical: Bleeding, urinary tract injury (most common complication of hysterectomy) 4

This anesthesia plan prioritizes hemodynamic stability, early recovery, and minimizes risks associated with the patient's comorbidities, particularly focusing on liver function and OSA concerns.