What is the recommended anesthetic plan for a 44-year-old female with bronchial asthma, scheduled for elective laparoscopic hysterectomy due to multiple myoma uteri with potential malignant degeneration?

Anesthetic Plan for Elective Laparoscopic Hysterectomy in Patient with Bronchial Asthma

General endotracheal anesthesia (GETA) is appropriate for this patient, with mandatory preoperative optimization of her asthma control, comprehensive airway assessment, and preparation for potential difficult airway management given her body habitus and large abdominopelvic mass.

Preoperative Optimization

Asthma Management

• Administer intravenous corticosteroids (hydrocortisone 100-200mg or dexamethasone 8mg) preoperatively to prevent perioperative bronchospasm, as this is the most effective preventive measure for asthmatic patients undergoing general anesthesia 1, 2.
• Continue her salbutamol availability and ensure optimal asthma control is achieved before proceeding, as inadequately controlled bronchial hyperreactivity represents the most important risk factor for life-threatening bronchospasm during anesthesia 2.
• The patient's asthma appears well-controlled (last attack was remote, currently no acute symptoms), which is favorable 2, 3.

Aspiration Prophylaxis

• Administer H2-receptor antagonist intravenously plus sodium citrate 30 mL immediately before induction 4, 5.
• Ensure NPO status: no food for 6 hours, clear fluids up to 2 hours preoperatively 4.
• Consider metoclopramide as a prokinetic agent given the large abdominopelvic mass which may delay gastric emptying 4.

Airway Assessment

• Document Mallampati grade, mouth opening (>3cm), thyromental distance (>6cm), neck extension, and jaw protrusion 4, 5.
• The patient shows concerning features: BMI 28.1, short stature (145cm), large abdominopelvic mass (32x30x16cm), and hesitation to speak suggesting potential airway compromise 4.
• Have difficult airway equipment immediately available including videolaryngoscope, supraglottic airways, and front-of-neck access equipment 4.

Intraoperative Management

Anesthetic Induction

• Use propofol for induction (1.5-2.5 mg/kg) as it provides bronchodilation and inhibits bronchoconstriction 3.
• Ketamine (1-2 mg/kg) is an alternative that also inhibits bronchoconstriction 3.
• Avoid thiopental and etomidate as they are less reliable for preventing bronchospasm 3.

Airway Management

• Perform rapid sequence induction with cricoid pressure given aspiration risk 4.
• Administer rocuronium (1.2 mg/kg) for neuromuscular blockade, as it does not induce bronchospasm and can be reversed with sugammadex if needed 4, 3.
• Avoid atracurium and mivacurium as they can release histamine dose-dependently 3.
• Consider lidocaine 1.5 mg/kg IV 2-3 minutes before intubation to minimize airway reactivity 3.
• Limit total lidocaine dose to 8.2 mg/kg (approximately 492mg for this 60kg patient) 4.

Maintenance of Anesthesia

• Use sevoflurane or isoflurane for maintenance as volatile anesthetics are potent bronchodilators 5, 3.
• Halothane, enflurane, and isoflurane have proven efficacy even in status asthmaticus 3.
• Maintain total intravenous anesthesia (TIVA) with propofol infusion as an alternative if volatile agents are contraindicated 6.

Ventilation Strategy

• Maintain end-tidal CO2 between 30-35 mmHg to optimize uteroplacental blood flow (though not pregnant, this represents optimal ventilation parameters) 5.
• Use pressure-controlled ventilation with adequate PEEP to prevent atelectasis.
• Monitor peak airway pressures continuously for early detection of bronchospasm 4.

Positioning

• Maintain left uterine displacement or reverse Trendelenburg position to minimize compression from the large abdominopelvic mass on the diaphragm and great vessels 7.

Monitoring

• Continuous ECG, non-invasive blood pressure, pulse oximetry, capnography, and temperature 5.
• Maintain continuous multi-modal physiological monitoring throughout the procedure 4.
• Monitor for signs of bronchospasm: increased peak airway pressures, wheezing, decreased oxygen saturation, prolonged expiratory phase 2, 3.

Emergency Preparedness

Bronchospasm Management

• Have bronchodilators immediately available: inhaled albuterol, intravenous aminophylline, additional corticosteroids 1, 2.
• Deepen anesthesia with propofol or volatile agents if bronchospasm occurs 3.

Failed Intubation Plan

• If intubation fails, proceed to supraglottic airway device (second-generation preferred) and maintain oxygenation 4.
• If "can't intubate, can't oxygenate" situation develops, proceed immediately to front-of-neck access 4.
• Have sugammadex available for immediate reversal of rocuronium if awakening is necessary 4.

Extubation Strategy

• Extubate only when fully awake, responsive to commands, maintaining oxygen saturation, and generating adequate tidal volumes 5.
• Consider deep extubation if airway reactivity is a concern, though this increases aspiration risk 3.
• Maintain high vigilance for laryngeal edema post-extubation, particularly given potential airway edema from positioning and large abdominal mass 5.
• Administer nebulized albuterol before extubation if any signs of bronchospasm 2, 3.

Postoperative Analgesia

• Multimodal analgesia with scheduled acetaminophen 1g IV/PO every 6-8 hours and ibuprofen 600mg PO every 6 hours 8.
• Avoid excessive opioids as they can suppress cough and ventilation in patients with respiratory disease 8.
• Consider transversus abdominis plane (TAP) blocks or port site infiltration with local anesthetic for additional analgesia 8.

Critical Pitfalls to Avoid

• Do not proceed if asthma is in acute exacerbation or poorly controlled 2.
• Do not use histamine-releasing neuromuscular blockers (atracurium, mivacurium) 3.
• Do not extubate until fully awake given aspiration risk and potential airway edema 5.
• Do not underestimate the difficult airway potential in this patient with short stature, obesity, and large abdominal mass 4, 5.