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Matsuoka T, Ishiyama T, Shintani N, Kotoda M, Mitsui K, Matsukawa T. Changes of cerebral regional oxygen saturation during pneumoperitoneum and Trendelenburg position under propofol anesthesia: a prospective observational study. BMC Anesthesiol 2019; 19:72. [PMID: 31092197 PMCID: PMC6521399 DOI: 10.1186/s12871-019-0736-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 04/18/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We evaluated the change of cerebral regional tissue oxygen saturation (rSO2) along with the pneumoperitoneum and the Trendelenburg position. We also assessed the relationship between the change of rSO2 and the changes of mean arterial blood pressure (MAP), heart rate (HR), arterial carbon dioxide tension (PaCO2), arterial oxygen tension (PaO2), or arterial oxygen saturation (SaO2). METHODS Forty-one adult patients who underwent a robotic assisted endoscopic prostatic surgery under propofol and remifentanil anesthesia were involved in this study. During the surgery, a pneumoperitoneum was established using carbon dioxide. Measurements of rSO2, MAP, HR, PaCO2, PaO2, and SaO2 were performed before the pneumoperitoneum (baseline), every 5 min after the onset of pneumoperitoneum, before the Trendelenburg position. After the onset of the Trendelenburg position, rSO2, MAP, HR were recorded at 5, 10, 20, 30, 45, and 60 min, and PaCO2, PaO2, and SaO2 were measured at 10, 30, and 60 min. RESULTS Before the pneumoperitoneum, left and right rSO2 were 67.9 ± 6.3% and 68.5 ± 7.0%. Ten minutes after the onset of pneumoperitoneum, significant increase in the rSO2 was observed (left: 69.6 ± 5.9%, right: 70.6 ± 7.4%). During the Trendelenburg position, the rSO2 increased initially and peaked at 5 min (left: 72.2 ± 6.5%, right: 73.1 ± 7.6%), then decreased. Multiple regression analysis showed that change of rSO2 correlated with MAP and PaCO2. CONCLUSIONS Pneumoperitoneum and the Trendelenburg position in robotic-assisted endoscopic prostatic surgery did not worsen cerebral oxygenation. Arterial blood pressure is the critical factor in cerebral oxygenation. TRIAL REGISTRATION Japan Primary Registries Network (JPRN); UMIN-CTR ID; UMIN000026227 (retrospectively registered).
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Affiliation(s)
- Toru Matsuoka
- Department of Anesthesiology, Faculty of Medicine, University of Yamanashi, Chuo, Yamanashi, Japan
| | - Tadahiko Ishiyama
- Surgical Center, University of Yamanashi Hospital, University of Yamanashi, 1110 Shimokato, Chuo, Yamanashi, 409-3898, Japan.
| | - Noriyuki Shintani
- Surgical Center, University of Yamanashi Hospital, University of Yamanashi, 1110 Shimokato, Chuo, Yamanashi, 409-3898, Japan
| | - Masakazu Kotoda
- Department of Anesthesiology, Faculty of Medicine, University of Yamanashi, Chuo, Yamanashi, Japan
| | - Kazuha Mitsui
- Surgical Center, University of Yamanashi Hospital, University of Yamanashi, 1110 Shimokato, Chuo, Yamanashi, 409-3898, Japan
| | - Takashi Matsukawa
- Department of Anesthesiology, Faculty of Medicine, University of Yamanashi, Chuo, Yamanashi, Japan
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Rosendal C, Markin S, Hien MD, Motsch J, Roggenbach J. Cardiac and hemodynamic consequences during capnoperitoneum and steep Trendelenburg positioning: lessons learned from robot-assisted laparoscopic prostatectomy. J Clin Anesth 2014; 26:383-9. [PMID: 25086483 DOI: 10.1016/j.jclinane.2014.01.014] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Revised: 01/01/2014] [Accepted: 01/19/2014] [Indexed: 11/24/2022]
Abstract
STUDY OBJECTIVE To determine and interpret the changes in preload, afterload, and cardiac function in the different phases of robot-assisted laparoscopic prostatectomy. DESIGN Prospective, observational monocenter study. SETTING Operating room at a university hospital. PATIENTS 31 consecutive, ASA physical status 1, 2, and 3 patients. INTERVENTIONS Observations were made at 5 distinct time points: baseline after induction of anesthesia, after initiation of capnoperitoneum, immediately after a 45° head-down tilt, 15 minutes after the 45° head-down tilt was established, after the release of the capnoperitoneum, and 5 minutes after the patient was returned to a horizontal position (end). MEASUREMENTS Transpulmonary thermodilution and pulse contour analysis were used to record hemodynamic changes in preload, afterload, and cardiac function. MAIN RESULTS While central venous pressure increased threefold from baseline, none of the other preload parameters showed excessive fluid overload or demand. There was no significant change in cardiac contractility over time. Afterload increased significantly during the capnoperitoneum and significantly decreased compared with baseline after the release of abdominal pressure at the end of the procedure. Heart rate and cardiac index increased significantly during robot-assisted laparoscopic prostatectomy. CONCLUSIONS Selective arterial vasodilation at the time of capnoperitoneum may normalize afterload and myocardial oxygen demand.
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Affiliation(s)
- Christian Rosendal
- Hirslanden Clinics Berne, Klinik Beau-Site, Schänzlihalde 11, 3000 Bern 25, Switzerland; Department of Anesthesiology, University of Heidelberg, INF 110, 69120 Heidelberg, Germany.
| | - Sergei Markin
- Department of Anesthesiology, University of Heidelberg, INF 110, 69120 Heidelberg, Germany
| | - Maximilian D Hien
- Research Training Group 1126, University of Heidelberg, German Research Foundation (DFG), INF 110, 69120 Heidelberg, Germany; Department of Pediatrics, University of Heidelberg, INF 430, 69120 Heidelberg, Germany
| | - Johann Motsch
- Department of Anesthesiology, University of Heidelberg, INF 110, 69120 Heidelberg, Germany
| | - Jens Roggenbach
- Department of Anesthesiology, University of Heidelberg, INF 110, 69120 Heidelberg, Germany
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Abstract
This review focuses on the available literature published about the evaluation of haemodynamic consequences of the abdominal compartment syndrome (ACS). Animal and clinical studies described decreased venous return, systemic vasoconstriction, systolic and diastolic dysfunction of left and right ventricles. Doppler echocardiography is a non-invasive bedside procedure which provides a complete haemodynamic evaluation of patients with ACS. Despite numerous evaluations in anesthesia during laparoscopic surgery, the use of echocardiography remains scarce in critically ill patients with ACS.
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Moon HS, Lee SK, Choi YS, In CB, Choi EJ. The effect of nitroglycerin on hemodynamic changes during laparoscopic low anterior resection. Korean J Anesthesiol 2011; 61:388-93. [PMID: 22148087 PMCID: PMC3229017 DOI: 10.4097/kjae.2011.61.5.388] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2011] [Revised: 05/23/2011] [Accepted: 05/23/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND More laparoscopic low anterior resections (LAR) are being performed in recent years. There has been controversy around the hemodynamic changes affected by the Trendelenburg position and pneumoperitoneum during LAR. The goal of this study was to analyze the effect of nitroglycerin (NTG) on hemodynamic changes during LAR. METHODS Forty ASA physical status I-II patients undergoing LAR were randomized into two groups: the NTG infused group (N group, n = 20) and the control group (C group, n = 20). Anesthesia was maintained with sevoflurane at 1-3 vol%, air/oxygen (50%/50%) and continuous infusion with remifentanil. The N group patients were given 0.5 µg/kg/min of NTG during anesthesia. Mean arterial pressure (MAP), heart rate (HR), central venous pressure (CVP), cardiac index (CI), stroke volume (SV) and systemic vascular resistance (SVR) were assessed 10 min after induction (T1), 5 min after pneumoperitoneum in the supine position (T2), 10 min after pneumoperitoneum in the Trendelenburg position (T3), 30 min after pneumoperitoneum in the Trendelenburg position (T4), 1 hr after pneumoperitoneum in the Trendelenburg position (T5) in addition to 5 (T6), 10 (T7) and 30 min (T8) after removal of the pneumoperitoneum in the supine position. RESULTS The increases of MAP were milder in the N group (22.6-7.3%) than the C group (32.3-17.7%) during pneumoperitoneum and while in the Trendelenburg position. The significant decreases of HR were maintained in the C group, but the changes in HR were not significant in N group during the operation. The increases in CVP were less in N group than C group. The increases of SVR were milder in N group (19.4-1.4%) than C group (41.7-16.6%) during pneumoperitoneum in the Trendelenburg position. CONCLUSIONS Intraoperative NTG infusions were effective to some degree in reducing the hemodynamic changes during pneumoperitoneum with Trendelenburg positioning for LAR.
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Affiliation(s)
- Hyun Soo Moon
- Department of Anesthesiology and Pain Medicine, College of Medicine, Hallym University, Anyang, Korea
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Lo Monte AI, Damiano G, Palumbo VD, Zumbino C, Spinelli G, Sammartano A, Bellavia M, Buscemi G. Eight-point Compass Rose Underlay Technique in 72 Consecutive Elderly Patients with Large Incisional Hernia. INT J GERONTOL 2011. [DOI: 10.1016/j.ijge.2011.09.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Bliacheriene F, Machado SB, Fonseca EB, Otsuke D, Auler JOC, Michard F. Pulse pressure variation as a tool to detect hypovolaemia during pneumoperitoneum. Acta Anaesthesiol Scand 2007; 51:1268-72. [PMID: 17714573 DOI: 10.1111/j.1399-6576.2007.01432.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Pulse pressure variation (DeltaPP) and systolic pressure variation (SPV) induced by mechanical ventilation have been proposed to detect hypovolaemia and guide fluid therapy. During laparoscopic surgery, chest compliance is decreased by pneumoperitoneum. This may affect the value of SPV and DeltaPP as indicators of intravascular volume status. Thereby, we investigated the effects of pneumoperitoneum and hypovolaemia on SPV and DeltaPP. METHODS We measured DeltaPP, SPV and the inspiratory (Deltaup) and expiratory (Deltadown) components of SPV, at baseline, during pneumoperitoneum, during pneumoperitoneum and hypovolaemia and after the return to baseline conditions, in 11 mechanically ventilated rabbits. Pneumoperitoneum was induced by inflating the abdomen with carbon dioxide, and hypovolaemia was induced by controlled haemorrhage. RESULTS Pneumoperitoneum induced an increase in SPV from 8.5 +/- 1.6 to 13.3 +/- 2.6 mmHg (+56%, P < 0.05) as a result of an increase in Deltaup from 2.0 +/- 1.0 to 6.7 +/- 2.1 mmHg (+236%, P < 0.05), but no significant change in Deltadown, nor in DeltaPP. Haemorrhage induced a significant (P < 0.05) increase in SPV from 13.3 +/- 2.6 to 19.9 +/- 3.7 mmHg (+50%), in Deltadown from 6.6 +/- 3.3 to 14.0 +/- 4.9 mmHg (+112%) and in DeltaPP from 11.1 +/- 4.8 to 24.9 +/- 9.8% (+124%) but no change in Deltaup. All parameters returned to baseline values after blood re-infusion and abdominal deflation. CONCLUSIONS SPV is modified by haemorrhage but it is also influenced by pneumoperitoneum. In contrast, DeltaPP is modified by haemorrhage but not by pneumoperitoneum. These findings suggest that DeltaPP should be used preferentially instead of SPV to detect hypovolaemia and guide fluid therapy during laparoscopic surgery.
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Affiliation(s)
- F Bliacheriene
- Clinical Investigation Laboratory L. I. M. 8 School of Medicine-University of Sao Paulo, Sao Paulo, Brazil.
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Tosun M, Samli H, Arikan Y, Solak M, Sahin A, Söylemez Z, Kalkan S. The effects of CO2 pneumoperitoneum on the apoptotic index in the peritoneum. Adv Ther 2007; 24:883-9. [PMID: 17901037 DOI: 10.1007/bf02849981] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
During laparoscopic surgery, gases such as carbon dioxide (CO(2)), helium, or normal air are insufflated into the intra-abdominal cavity so the surgeon can obtain a clear surgical field; however, this insufflation technique may cause injury to the intra-abdominal organs. This study was undertaken to evaluate the effects of different pressures of CO(2) on the apoptotic index in the peritoneum during laparoscopic surgery. A total of 30 Sprague-Dawley male rats were used in the study. CO(2) was insufflated into the intra-abdominal cavity via an angiocatheter cannula by an insufflator at pressures of 10 and 20 mm Hg over 60 min. In the control group, the cannula was inserted into the intra-abdominal cavity, but no gas was insufflated. After 60 min, the rats were killed; peritoneum was harvested from the abdominal wall and was cultured in the cell culture laboratory. Apoptotic and living cells were detected immunohistochemically, and the apoptotic index was calculated and statistically analyzed. The data collected revealed that the apoptotic index increases in proportion to the level of CO(2) pressure. CO(2) pneumoperitoneum is a very useful technique. Gas pressure must be carefully set during the operation, however, or injured mesothelial cells may cause serious malfunction.
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Affiliation(s)
- Murat Tosun
- Department of Histology/Embryology, Afyon Kocatepe University Medical Faculty, Konya, Turkey.
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Takahata O, Kunisawa T, Nagashima M, Mamiya K, Sakurai K, Fujita S, Fujimoto K, Iwasaki H. Effect of age on pulmonary gas exchange during laparoscopy in the Trendelenburg lithotomy position. Acta Anaesthesiol Scand 2007; 51:687-92. [PMID: 17465975 DOI: 10.1111/j.1399-6576.2007.01311.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Physiological changes in respiratory mechanics caused by aging may lead to a deterioration in pulmonary gas exchange, an increase in the alveolar-arterial oxygen gradient [(A-a)D(O2)] and a difference between the arterial carbon dioxide (CO(2)) tension (P(a)(CO(2))) and expired end-tidal CO(2) tension (P(ET)(CO(2))) [P((a-ET))(CO(2))] during laparoscopy in the Trendelenburg lithotomy position (TLP). METHODS The subjects were 51 gynecologic patients. Pressure-controlled ventilation was used to maintain P(ET)(CO(2)), measured by the side stream method, within the range 4-4.67 kPa. During laparoscopy with CO(2) insufflation in TLP, the tidal volume was increased to keep P(ET)(CO(2)) within +/- 20% of the pre-insufflation value. The subjects were divided into three groups by age: young group (< 45 years); middle-aged group (45-64 years); and elderly group ( > or = 65 years). RESULTS Before pneumoperitoneum (PPN), significant differences were found between the young and elderly groups in the arterial oxygen tension (P(a)(O(2))), (A-a)D(O(2)), P(a)(CO(2)) and P((a-ET))(CO(2)). In all groups, the peak inspiratory pressure and P(a)(CO(2)) increased progressively during PPN in TLP. P((a-ET))(CO(2)) increased gradually after starting CO(2) insufflation in TLP only in the elderly group. CONCLUSIONS An increase in P((a-ET))(CO(2)) was seen during PPN in TLP in the elderly group. With CO(2) insufflation in TLP, the setting of mechanical ventilation based on the value of P(ET)(CO(2)) (measured by the side stream method) should be determined with caution in elderly patients.
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Affiliation(s)
- O Takahata
- Department of Anesthesiology and Critical Care Medicine, Asahikawa Medical College, Hokkaido, Japan.
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9
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Delia Rocca G, Costa MG. Intrathoracic Blood Volume: Clinical Applications. Intensive Care Med 2006. [DOI: 10.1007/0-387-35096-9_14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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10
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Andersson LE, Jogestrand T, Thörne A, Sollevi A, Odeberg-Wernerman S. Are there changes in leg vascular resistance during laparoscopic cholecystectomy with CO2 pneumoperitoneum? Acta Anaesthesiol Scand 2005; 49:360-5. [PMID: 15752402 DOI: 10.1111/j.1399-6576.2005.00623.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The prompt haemodynamic response to carbon dioxide insufflation during laparoscopic cholecystectomy suggests involvement of the sympathetic system. The aim of the present study was to examine if a change in vascular resistance in leg skeletal muscle could be an important mechanism behind the increased afterload. Furthermore, the arterio-venous differences of the catecholamines were measured in the leg before and during insufflation of carbon dioxide into the peritoneal cavity. METHODS Ten patients (ASA I) scheduled for laparoscopic cholecystectomy were included. After induction of anaesthesia, catheters were introduced percutaneously into the radial artery, the femoral vein and the cubital vein for pressure monitoring and blood sampling. The arterial blood flow in the legs was measured by mercury-in-Silastic strain gauge venous occlusion plethysmography. Vascular resistance in the right leg (LVR) was calculated from the formula: (MAP-FVP)/calf blood flow. Measurements were made before and 5 min after insufflation of pneumoperitoneum. RESULTS Induction of pneumoperitoneum increased the heart rate (P < 0.05) and also increased mean arterial pressure and femoral vein pressure as well as the calculated leg vascular resistance (P < 0.01). Calf blood flow did not change significantly in either leg. Both arterial and venous noradrenaline concentrations were higher after insufflation (P < 0.01). CONCLUSION In patients without heart or lung disease, pneumoperitoneum at an intra-abdominal pressure level of 11-13 mmHg increased the peripheral vascular resistance in the leg while the arterial blood flow in the leg was unaffected. Catecholamine levels increased, but were still low. Therefore, we suggest that the increase in peripheral vascular resistance is caused by increased myogenic activity in the resistance vessels secondary to increased arterial and transmural pressure rather than by increased neurogenic sympathetic activity.
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Affiliation(s)
- L E Andersson
- Department of Anaesthesiology and Intensive Care, Karolinska University Hospital, S-141 86 Huddinge, Sweden.
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Valenza F, Irace M, Guglielmi M, Gatti S, Bottino N, Tedesco C, Maffioletti M, Maccagni P, Fossali T, Aletti G, Gattinoni L. Effects of continuous negative extra-abdominal pressure on cardiorespiratory function during abdominal hypertension: an experimental study. Intensive Care Med 2004; 31:105-11. [PMID: 15517159 DOI: 10.1007/s00134-004-2483-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2003] [Accepted: 10/04/2004] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To investigate whether negative extra-abdominal pressure (NEXAP) improves respiratory function and induces a blood shift from the intrathoracic compartment and to assess whether these effects are influenced by abdominal pressure. DESIGN AND SETTING Prospective, randomized, controlled trial in the animal laboratory of a university hospital. SUBJECTS Eight sedated and paralyzed pigs (19.6+/-3.4 kg). INTERVENTIONS Application of NEXAP (-20 cmH(2)O). MEASUREMENTS AND RESULTS Airway, esophageal, gastric and central venous pressures were recorded simultaneously. Intrathoracic blood volume was assessed by PiCCO. The effects of NEXAP were assessed with and without abdominal hypertension by intraperitoneal insufflation of helium. NEXAP caused a lasting drop of gastric (1.97+/-2.26 mmHg) and esophageal (1.21+/-0.67 mmHg) pressures, while end-expiratory airway pressure was similar, hence transpulmonary pressure increased. Intrathoracic blood volume dropped from 358+/-47 to 314+/-47 ml. The fall was associated with a decrease in central venous pressure (R(2)=0.820). When peritoneal pressure was raised (24.7+/-5.5 mmHg), the effects were less marked. However, the difference between negative pressure around the abdomen and the pressure inside the abdomen (effective NEXAP) was correlated with the proportional changes in intrathoracic blood volume (R(2)=0.648), being greater with more negative effective NEXAP. NEXAP improved chest wall elastance during abdominal hypertension (from 0.067+/-0.023 to 0.056+/-0.021 cmH(2)O/ml). CONCLUSIONS NEXAP increases lung volume and causes a shift of blood from the intrathoracic compartment. It needs to be tailored against abdominal pressure to be effective.
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Affiliation(s)
- Franco Valenza
- Istituto di Anestesia e Rianimazione, Ospedale Maggiore di Milano-Istituto di Ricovero e Cura a Carattere Scientifico, Università degli Studi di Milano, Via F. Sforza 35, 20122 Milan, Italy
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Larsen JF, Svendsen FM, Pedersen V. Randomized clinical trial of the effect of pneumoperitoneum on cardiac function and haemodynamics during laparoscopic cholecystectomy. Br J Surg 2004; 91:848-54. [PMID: 15227690 DOI: 10.1002/bjs.4573] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Conventional laparoscopic cholecystectomy (CLC) with carbon dioxide pneumoperitoneum may cause major cardiovascular changes. The aim of this study was to evaluate the effect of carbon dioxide pneumoperitoneum and positional changes on haemodynamics and cardiac function in patients assigned randomly to CLC or gasless laparoscopic cholecystectomy (GLC). METHODS Fifty patients with American Society of Anesthesiologists physical status I and II were randomly allocated to CLC (28 patients) or GLC (22). Left ventricular end-diastolic and end-systolic diameters, fractional shortening and cardiac output were determined by transoesophageal echocardiography. Measurements were performed before (phase 1) and 10 and 30 min (phases 2 and 3 respectively) after pneumoperitoneum or abdominal wall traction, and after desufflation or release of abdominal wall traction (phase 4) in supine, Trendelenburg and reverse Trendelenburg positions. RESULTS Mean diastolic diameter, systolic diameter, mean arterial pressure and heart rate were significantly higher, and fractional shortening was significantly lower, with carbon dioxide pneumoperitoneum than with the gasless procedure during phases 2 and 3. There were no significant differences in cardiac output between the two groups. CONCLUSION Carbon dioxide pneumoperitoneum was associated with increased preload and afterload in patients undergoing laparoscopic cholecystecomy. It also decreased heart performance (fractional shortening), but did not affect cardiac output.
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Affiliation(s)
- J F Larsen
- Department of Surgical Gastroenterology, University Hospital of Aalborg, Aalborg, Denmark.
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Quintel M, Pelosi P, Caironi P, Meinhardt JP, Luecke T, Herrmann P, Taccone P, Rylander C, Valenza F, Carlesso E, Gattinoni L. An increase of abdominal pressure increases pulmonary edema in oleic acid-induced lung injury. Am J Respir Crit Care Med 2003; 169:534-41. [PMID: 14670801 DOI: 10.1164/rccm.200209-1060oc] [Citation(s) in RCA: 145] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Increased abdominal pressure is common in intensive care unit patients. To investigate its impact on respiration and hemodynamics we applied intraabdominal pressure (aIAP) of 0 and 20 cm H(2)O (pneumoperitoneum) in seven pigs. The whole-lung computed tomography scan and a complete set of respiratory and hemodynamics variables were recorded both in healthy lung and after oleic acid (OA) injury. In healthy lung, aIAP 20 cm H(2)O significantly lowered the gas content, leaving the tissue content unchanged. In OA-injured lung at aIAP 0 cm H(2)O, the gas content significantly decreased compared with healthy lung. The excess tissue mass (edema) amounted to 30 +/- 24% of the original tissue weight (455 +/- 80 g). The edema was primarily distributed in the base regions and was not gravity dependent. Heart volume, central venous, pulmonary artery, wedge, and systemic arterial pressures significantly increased. At aIAP 20 cm H(2)O in OA-injured lung, the central venous and pulmonary artery pressures further increased. The gas content further decreased, and the excess tissue mass rose up to 103 +/- 37% (tissue weight 905 +/- 134 g), with homogeneous distribution along the cephalocaudal and sternovertebral axis. We conclude that in OA-injured lung, the increase of IAP increases the amount of edema.
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Affiliation(s)
- Michael Quintel
- Institut für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum, Mannheim, Mannheim, Germany
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Andersson L, Lindberg G, Bringman S, Ramel S, Anderberg B, Odeberg-Wernerman S. Pneumoperitoneum versus abdominal wall lift: effects on central haemodynamics and intrathoracic pressure during laparoscopic cholecystectomy. Acta Anaesthesiol Scand 2003; 47:838-46. [PMID: 12859305 DOI: 10.1034/j.1399-6576.2003.00117.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND It has been shown repeatedly that laparoscopic cholecystectomy using pneumoperitoneum (CO2 insufflation) may be associated with increased cardiac filling pressures and an increase in blood pressure and systemic vascular resistance. In the present study, the effects on the central circulation during abdominal wall lift (a gasless method of laparoscopic cholecystectomy) were compared with those during pneumoperitoneum. The study was also aimed at elucidating the relationships between the central filling pressures and the intrathoracic pressure. METHODS Twenty patients (ASA I), scheduled for laparoscopic cholecystectomy, were randomised into two groups, pneumoperitoneum or abdominal wall lift. Measurements were made by arterial and pulmonary arterial catheterization before and during pneumoperitoneum or abdominal wall lift with the patient in the horizontal position. Measurements were repeated after head-up tilting the patients as well as after 30 min head-up tilt. The intrathoracic pressure was monitored in the horizontal position before and during intervention using an intraesophageal balloon. RESULTS After pneumoperitoneum or abdominal wall lifting there were significant differences between the two groups regarding MAP, SVR, CVP, CI, and SV. Analogous to previous studies, in the pneumoperitoneum group CVP, PCWP, MPAP, and MAP as well as SVR were increased after CO2 insufflation (P < 0.01), while CI and SV were not affected. In contrast, in the abdominal wall lift group, CI and SV were significantly increased (P < 0.01), as was MAP (P < 0.01), while CVP, PCWP, MPAP, and SVR were not significantly affected. There was a significant difference in intraesophageal pressure between the two groups. In the pneumoperitoneum group, the intraesophageal pressure was increased by insufflation (P < 0.01) while, in the abdominal wall lift group, it was unaffected. In the pneumoperitoneum group the mean increases in cardiac filling pressures were of the same magnitude as the mean increase in the intraesophageal pressure. CONCLUSIONS In healthy patients, abdominal wall lift increased cardiac index while pneumoperitoneum did not. Cardiac filling pressures and systemic vascular resistance were increased by pneumoperitoneum but unaffected by abdominal wall lift. The recorded elevated cardiac filling pressures during pneumoperitoneum may be only a reflection of the increased intra-abdominal pressure.
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Affiliation(s)
- L Andersson
- Department of Anaesthesiology and Intensive Care, Huddinge University Hospital, Stockholm, Sweden.
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Lindström P, Källskog O, Wadström J, Persson AEG. Blood flow distribution during elevated intraperitoneal pressure in the rat. ACTA PHYSIOLOGICA SCANDINAVICA 2003; 177:149-56. [PMID: 12558551 DOI: 10.1046/j.1365-201x.2003.01056.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
AIM Oliguria is seen during elevated intraperitoneal pressure, but the physiological mechanisms are not yet clarified. The purpose of the present study was to investigate the changes in renal function, cardiac output and distribution of systemic blood flow (BF) that occur in connection with an elevation of intra-abdominal pressure (IAP) in a rat model by isotope-labelled microsphere technique. METHODS A 5 or 10 mmHg IAP was created by CO2 insufflation and maintained for 90 min in anaesthetized and mechanically ventilated rats. Rats with normal IAP served as controls. Blood flow and cardiac output measurements by injection of isotope-labelled microspheres were conducted at three time points. Acid-base balance, urine output, glomerular filtration rate (GFR) and urinary excretion products were also followed. RESULTS Glomerular filtration rate decreased [0.7-0.1 mL min(-1) g(-1) kidney weight (KW)] with elevated IAP, as did urine output (8.5-0.6 microL min(-1) g(-1) KW). Dramatic decreases were seen in renal excretion of sodium (by 97%), potassium (by 94%) and osmotic active substances (by 93%). Cardiac output was diminished by 54% at 5 mmHg and by 65% at 10 mmHg intraperitoneal pressure and systemic vascular resistance (SVR) was elevated threefold. CONCLUSION Cardiac output, measured by microsphere technique, decreased during elevated intraperitoneal pressure by CO2 in anaesthetized rats, while SVR was elevated and renal excretory functions were decreased to a large extent.
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Affiliation(s)
- P Lindström
- Division of Integrative Physiology, Department of Medical Cell Biology, Uppsala University, Sweden
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Andersson L, Lagerstrand L, Thörne A, Sollevi A, Brodin LA, Odeberg-Wernerman S. Effect of CO(2) pneumoperitoneum on ventilation-perfusion relationships during laparoscopic cholecystectomy. Acta Anaesthesiol Scand 2002; 46:552-60. [PMID: 12027850 DOI: 10.1034/j.1399-6576.2002.460513.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Previous studies have shown that pneumoperitoneum transiently reduces venous admixture as assessed by a calculation based on the shunt formula, and increases arterial oxygen tension (PaO(2)) in patients without heart or lung disease. The aim of the present study was to further explore the relationship between ventilation-perfusion (V(A)/Q) before and during pneumoperitoneum by using the multiple inert gas technique. METHODS Nine patients without heart or lung disease (ASA I), with a mean age of 42 years, scheduled for laparoscopic cholecystectomy were included. After premedication and induction of anaesthesia, radial artery and pulmonary artery catheters were introduced percutaneously. The V(A)Q relationships were evaluated by the multiple inert gas elimination technique before and during pneumoperitoneum to obtain a direct measure of the pulmonary shunt. RESULTS Induction of pneumoperitoneum decreased the pulmonary shunt from 5.8 (4.5) to 4.1 (3.2)% (P<0.05) and increased PaO(2) from 21.7 (5.9) to 24.7 (4.8) kPa (P<0.01). During surgery, the shunt increased from 3.2 (2.8) to 5.2 (3.4)% to the same level as before pneumoperitoneum induction. No area with low V(A)Q was seen. Dead space ventilation amounted to 20.0 (1.2)% in the supine position and did not change during the investigation. CONCLUSIONS In patients without heart or lung disease, pneumoperitoneum at an intra-abdominal pressure level of 11-13 mmHg causes a transient reduction of the pulmonary shunt. The mechanisms underlying the present finding remain to be elucidated.
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Affiliation(s)
- L Andersson
- Department of Anaesthesiology, Huddinge University Hospital, Stockholm, Sweden.
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Hofer CK, Zalunardo MP, Klaghofer R, Spahr T, Pasch T, Zollinger A. Changes in intrathoracic blood volume associated with pneumoperitoneum and positioning. Acta Anaesthesiol Scand 2002; 46:303-8. [PMID: 11939922 DOI: 10.1034/j.1399-6576.2002.t01-1-460313.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND It is still controversial whether elevated cardiac filling pressures after the onset of pneumoperitoneum are the consequence of increased intrathoracic pressure or of increased venous return. The aim of this study was to assess the effects of pneumoperitoneum and body positioning on intrathoracic blood volume (ITBV). METHODS Thirty anesthetized patients were randomly assigned to have CO2-pneumoperitoneum (13 mmHg) either in a supine, in a 15 degrees head-up tilt or in a 15 degrees head-down tilt position. Measurements of ITBV and hemodynamics by the double indicator method were recorded after induction of anesthesia and application of a fluid bolus (Lactated Ringer's solution 10 ml/kg), after positioning and after induction of pneumoperitoneum. RESULTS Intrathoracic blood volume index (ITBVI) increased significantly after induction of pneumoperitoneum in all body positions (supine: from 18.5 +/- 3.3 -20.2 +/- 5.2 ml/kg (+6%) head-up from 16.7 +/- 3.8 - 17.4 +/- 3.7 ml/kg (+16%) and head-down: from 19.8 +/- 5.6 - 20.5 +/- 5.9 ml/kg (+14%)). Heart rate did not change significantly in any of the groups. Cardiac index showed a statistically significant change in the head-down position with pneumoperitoneum (-11%). A good correlation was found for stroke volume (SV) with ITBV (r = 0.79), but not with central venous pressure (r = 0.26). Systemic vascular resistance index increased significantly in all three groups (supine +6%, head-up +16%, head-down position +14%). CONCLUSION The present study indicates that the onset of pneumoperitoneum, even with moderate intra-abdominal pressures, is associated with an increased intrathoracic blood volume in ASA I/II patients.
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Affiliation(s)
- C K Hofer
- Institute of Anesthesiology, Triemli City Hospital, Zurich, Switzerland
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Kheirabadi BS, Tuthill D, Pearson R, Bayer V, Beall D, Drohan W, MacPhee MJ, Holcomb JB. Metabolic and hemodynamic effects of CO2 pneumoperitoneum in a controlled hemorrhage model. THE JOURNAL OF TRAUMA 2001; 50:1031-43. [PMID: 11426117 DOI: 10.1097/00005373-200106000-00010] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Intracavity infusion of fibrin sealant-based agents, as a novel modality to control internal bleeding, is associated with an increase of pneumoperitoneum (PP) pressure. The safe limit of such increase has not been well defined in hypovolemic subjects. The purpose of this study was to evaluate the hemodynamic and metabolic effects of increasing PP pressure and to define the limits of carbon dioxide (CO2) insufflation in a controlled hemorrhage rat model. METHODS Ninety male rats (474 +/- 6 g, 37 degrees +/- 1 degrees C) were anesthetized, and mechanically ventilated. Animals were randomly distributed among 14 groups (n = 6-8) with an increasing amount of blood loss (0, 10, 15, and 17.5 mL/kg) and 15 minutes of CO2 insufflation at 0, 5, 10, and 15 mm Hg starting 15 minutes after hemorrhage, followed by desufflation. Mean arterial pressure (MAP), heart rate, and survival were recorded and arterial and venous blood samples were collected at baseline, at 15 minutes after hemorrhage, after insufflation, and after desufflation procedures to determine arterial blood gases and lactic acid levels. RESULTS In nonhemorrhaged animals, increasing PP pressure up to 15 mm Hg produced only transient changes in MAP and no increase in lactate level. A moderate hemorrhage (10 mL/kg) limited the safe abdominal pressure to 10 mm Hg with metabolic changes that were restored 15 minutes after desufflation. Higher PP pressure (15 mm Hg) at this hemorrhage level produced a significant decline in MAP (42%, p < 0.001) and progressive metabolic acidosis with a 2.1-fold increase (p < 0.01) in lactate level. The more severe hemorrhage (15 mL/kg) further reduced the limits of PP pressure such that 10 and 15 mm Hg resulted in a progressive decline of blood pressures (52% and 54%, respectively; p < 0.001) and severe metabolic acidosis as manifested by 3.3- and 3.1-fold rises in lactate levels, respectively. In the most severe hemorrhaged animals (17.5 mL/kg), the 50% mortality was primarily determined by the severity of the blood loss and the additional PP at 5 mm Hg had no significant impact. CONCLUSION The safe limit of PP pressurization with CO2 is dependent on the amount of blood loss. In this mechanically ventilated rat model, increasing the amount of blood loss from 0 to 15 mL/kg reduces the tolerable level of abdominal insufflation pressure from 15 mm Hg to 5 mm Hg. A 5-mm Hg PP pressure appears safe even in the most severely hemorrhaged animals.
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Affiliation(s)
- B S Kheirabadi
- American Red Cross, Holland Laboratory, 15601 Crabbs Branch Way, Rockville, MD 20855, USA.
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Koivusalo AM, Lindgren L. Effects of carbon dioxide pneumoperitoneum for laparoscopic cholecystectomy. Acta Anaesthesiol Scand 2000; 44:834-41. [PMID: 10939696 DOI: 10.1034/j.1399-6576.2000.440709.x] [Citation(s) in RCA: 70] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- A M Koivusalo
- Department of Anaesthesia, Fourth Department of Surgery, Helsinki University Hospital, Finland
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