Continuous transesophageal echo-Doppler assessment of hemodynamic function during laparoscopic cholecystectomy

Internal Carotid Artery Blood Flow Response to Anesthesia, Pneumoperitoneum, and Head-up Tilt during Laparoscopic Cholecystectomy

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Background

Little is known about how implementation of pneumoperitoneum and head-up tilt position contributes to general anesthesia-induced decrease in cerebral blood flow in humans. We investigated this question in patients undergoing laparoscopic cholecystectomy, hypothesizing that cardiorespiratory changes during this procedure would reduce cerebral perfusion.

Methods

In a nonrandomized, observational study of 16 patients (American Society of Anesthesiologists physical status I or II) undergoing laparoscopic cholecystectomy, internal carotid artery blood velocity was measured by Doppler ultrasound at four time points: awake, after anesthesia induction, after induction of pneumoperitoneum, and after head-up tilt. Vessel diameter was obtained each time, and internal carotid artery blood flow, the main outcome variable, was calculated. The authors recorded pulse contour estimated mean arterial blood pressure (MAP), heart rate (HR), stroke volume (SV) index, cardiac index, end-tidal carbon dioxide (ETco2), bispectral index, and ventilator settings. Results are medians (95% CI).

Results

Internal carotid artery blood flow decreased upon anesthesia induction from 350 ml/min (273 to 410) to 213 ml/min (175 to 249; −37%, P < 0.001), and tended to decrease further with pneumoperitoneum (178 ml/min [127 to 208], −15%, P = 0.026). Tilt induced no further change (171 ml/min [134 to 205]). ETco2 and bispectral index were unchanged after induction. MAP decreased with anesthesia, from 102 (91 to 108) to 72 (65 to 76) mmHg, and then remained unchanged (Pneumoperitoneum: 70 [63 to 75]; Tilt: 74 [66 to 78]). Cardiac index decreased with anesthesia and with pneumoperitoneum (overall from 3.2 [2.7 to 3.5] to 2.3 [1.9 to 2.5] l · min−1 · m−2); tilt induced no further change (2.1 [1.8 to 2.3]). Multiple regression analysis attributed the fall in internal carotid artery blood flow to reduced cardiac index (both HR and SV index contributing) and MAP (P < 0.001). Vessel diameter also declined (P < 0.01).

Conclusions

During laparoscopic cholecystectomy, internal carotid artery blood flow declined with anesthesia and with pneumoperitoneum, in close association with reductions in cardiac index and MAP. Head-up tilt caused no further reduction. Cardiac output independently affects human cerebral blood flow.

Hemodynamic evaluation of elderly patients during laparoscopic cholecystectomy

OBJECTIVE

to demonstrate hemodynamic changes during laparoscopic cholecystectomy in elderly patients with trans-esophageal echocardiography.

METHODS

we studied 31 elderly patients (aged 60 years or older), ASA I or II, who underwent elective laparoscopic cholecystectomy under general, standardized anesthesia, with cardiovascular parameters measured using transesophageal echocardiography at three different times: before the pneumoperitoneum (T1), after CO2 insufflation (T2) and at deflation (T3). We statistically evaluated changes in systolic, diastolic and mean blood pressure, heart rate, cardiac output and index, and ejection fraction.

RESULTS

although small, only the diastolic blood pressure (DBP) and ejection fraction (EF) variations were statistically significant. The mean ± standard deviation of DBP in mmHg at the different times were: T1=67.5±10.3; T2=73.6±12.4; and T3=66.7±9.8. And for EF, in percentage (%) they were: T1=66.7±10.4; T2=63.2±9.9; and T3=68.1±8.4. There was no statistical correlation between hemodynamic variations, age and number of patients' comorbidities.

CONCLUSION

laparoscopic cholecystectomy causes few hemodynamic changes that are well tolerated by the majority of the elderly patients; prior impairment of ventricular function represents a threat in elderly patients during surgery; there appears to be a lower hemodynamic effect caused by the pneumoperitoneum than by the patient's positioning in a reverse Trendelemburg during surgery.

Changes in cerebral oxygen saturation and early postoperative cognitive function after laparoscopic gastrectomy: a comparison with conventional open surgery

BACKGROUND

Laparoscopic gastrectomy requires a reverse-Trendelenburg position and prolonged pneumoperitoneum and it could cause significant changes in cerebral homeostasis and lead to cognitive dysfunction. We compared changes in regional cerebral oxygen saturation (rSO2), early postoperative cognitive function and hemodynamic variables in patients undergoing laparoscopic gastrectomy with those patients that underwent conventional open gastrectomy.

METHODS

Sixty patients were enrolled in this study and the patients were distributed to receive either laparoscopic gastrectomy (laparoscopy group, n = 30) or open conventional gastrectomy (open group, n = 30). rSO2, end-tidal carbon dioxide tension, hemodynamic variables and arterial blood gas analysis were monitored during the operation. The enrolled patients underwent the mini-mental state examination 1 day before and 5 days after surgery for evaluation of early postoperative cognitive function.

RESULTS

Compared to baseline value, rSO2 and end-tidal carbon dioxide tension increased significantly in the laparoscopy group after pneumoperitoneum, whereas no change was observed in the open group. No patient experienced cerebral oxygen desaturation or postoperative cognitive dysfunction. Changes in mean arterial pressure over time were significantly different between the groups (P < 0.001).

CONCLUSIONS

Both laparoscopic and open gastrectomy did not induce cerebral desaturation or early postoperative cognitive dysfunction in patients under desflurane anesthesia. However, rSO2 values during surgery favoured laparoscopic surgery, which was possibly related to increased cerebral blood flow due to increased carbon dioxide tension and the effect of a reverse Trendelenburg position.

Intraoperative management of a carbon dioxide embolus in the setting of laparoscopic cholecystectomy for a patient with primary biliary cirrhosis: A case report

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We discuss appropriate detection and management of a carbon dioxide embolus.

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We review the pathologic hepatic changes in patients with primary biliary cirrhosis.

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We postulate that cirrhosis may increase the risk of a carbon dioxide embolus.

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We share an understanding that more invasive monitoring may be helpful, but ultimately hypervigilance from the anesthesia team is the number one safeguard.

INTRODUCTION

Carbon dioxide (CO₂) embolism is a rare complication of laparoscopic cholecystectomy of which both surgeons and anesthesiologists must be aware. This paper presents a case of a CO₂ embolus that occurred in a patient with primary biliary cirrhosis (PBC) and discusses the possible correlation between these two events.

PRESENTATION OF CASE

Our patient with PBC presented with symptomatic biliary dyskinesia and was determined to be a good candidate for laparoscopic cholecystectomy. During this routine surgery a CO₂ embolus entered through the altered hepatic parenchyma and progressed to the heart leading to acute hemodynamic collapse. Rapid detection and management aided in the subsequent dissolution of the embolus and recovery of the patient.

DISCUSSION

In patients with PBC, pathological changes that have taken place in the liver may increase the risk of CO₂ embolism. Hepatic alterations that have been previously described include increased angiogenesis and vasodilation. Prior to the operation, the most appropriate method of monitoring should be determined for patients with known liver disease.

CONCLUSION

Both the surgical and anesthesia team must keep in mind the potential for CO₂ embolism during laparoscopic surgery. It is imperative that the medical staff be aware of the risks, signs, and subsequent management so this rare, but potentially fatal event can be managed appropriately.

Non-invasive pulse wave analysis for monitoring the cardiovascular effects of CO2 pneumoperitoneum during laparoscopic cholecystectomy--a prospective case-series study

BACKGROUND

Peritoneal insufflation results in hemodynamic changes during laparoscopic cholecystectomy. The aim of the present work is to test whether non-invasive applanation tonometry is suitable for reflecting these hemodynamic alterations.

METHODS

41 patients undergoing laparoscopic cholecystectomies were monitored using the SphygmoCor pulse wave analysing system. Peripheral blood pressures (PBP), central aortic blood pressures (CBP), augmentation index (ALX@HR75) and subendocardial viability ratio (SVR) were measured at rest (Phase 1), after anesthetic induction (Phase 2), after peritoneal inflation (Phase 3) and after peritoneal deflation (Phase 4).

RESULTS

Induction of anesthesia resulted in a statistically significant reduction in both the peripheral blood pressure and central aortic pressures, accompanied by a decrease in augmentation pressure and augmentation index. Peripheral blood pressures did not change along with the peritoneal cavity insufflation, except for a moderate increase in systolic blood pressure. In contrast to this, an increase could be observed in central aortic pressure (106.77 ± 18.78 vs. 118.05 ± 19.85 mmHg, P < 0.01) which was accompanied by increased augementation pressure (18.97 ± 10.80 vs. 31.55 ± 12.01; P < 0.001) and augmentation index (7.31 ± 5.59 vs. 12.61 ± 7.56, P < 0.001), indicating a rise in peripheral arterial stiffness.

CONCLUSIONS

The Sphigmocor pulse wave analysis system can be reliably used for detecting and monitoring cardiovascular changes occurring during laparoscopic cholecystectomy.

Intra-operative oxygen delivery in infusion volume-optimized patients undergoing laparoscopic colorectal surgery within an enhanced recovery programme: the effect of different analgesic modalities

AIM

Patients undergoing major open surgery who have an indexed oxygen delivery (DO(2) I) > 600 ml/min/m(2) have been shown to have a lower incidence of morbidity and mortality compared with those whose DO(2) I is below this level. Laparoscopy and Trendelenburg positioning cause a reduction in DO(2) I. We aimed to quantify the effect of the type of analgesia on DO(2) I and to correlate the DO(2) I achieved with the incidence of anastomotic leakage in patients undergoing laparoscopic surgery.

METHOD

Following ethical approval, patients were randomized to receive spinal anaesthesia (Group S), epidural analgesia (Group E) or intravenous morphine (Group P) followed by postoperative patient-controlled analgesia (PCA). In addition to standard monitoring, oesophageal Doppler monitoring of the stroke volume allowed directed intravenous fluid therapy. The mean DO(2) I was compared with the anastomotic leakage rate.

RESULTS

Seventy-five patients were recruited (Group S, 27; Group E, 23; Group P, 25). The mean (range) DO(2) I for all patients was 490 (230-750) ml/min/m(2) . The analgesic modality had no effect on DO(2) I. Of the 18 patients with a DO(2) I of < 400 ml/min/m(2) , four (22%) developed anastomotic leakage compared with one (%) of the 57 patients with a DO(2) I of > 400 ml/min/m(2) (P = 0.01).

CONCLUSION

The analgesic modality used had no effect on the DO(2) I achieved. Anastomotic leakage was significantly higher in patients with a DO(2) I of < 400 ml/min/m(2) . A further study assessing the outcome after raising the DO(2) I with inotropes is required.

Hemodynamic and Respiratory Effects of Pediatric Urological Retroperitoneal Laparoscopic Surgery: A Prospective Study

PURPOSE

Our understanding of the effects of retroperitoneal CO(2) insufflation on cardiopulmonary variables in children remains limited. This study was designed to investigate prospectively the effect of CO(2) insufflation in a pediatric population undergoing retroperitoneal laparoscopic surgery.

MATERIALS AND METHODS

We prospectively evaluated a consecutive series of patients enrolled between July 2003 and August 2004. Anesthesia was administered following a standardized protocol. Data collection included respiratory rate, PAP, O(2) saturation, ETCO(2), HR, MAP, electrocardiogram and insufflation pressure. All variables were recorded before, during and after CO(2) insufflation at regular intervals of 1 to 2 minutes, with up to 23 measurements recorded for each period.

RESULTS

A total of 18 participants were recruited. Mean +/- SD for age and weight were 79.4 +/- 53.2 months and 26.7 +/- 15.5 kg, respectively. Mean retroperitoneal CO(2) insufflation pressure was kept at 12 mm Hg. Significant differences (p <0.05) in average ETCO(2), PAP and MAP were noted after CO(2) insufflation compared to baseline (pre-pneumoretroperitoneum) values. HR and temperature did not change. At completion of the laparoscopic intervention physiological variables exhibited a trend to return to baseline values.

CONCLUSIONS

This prospective study documents significant changes in systemic hemodynamic variables that seem to be directly associated with the insufflation of CO(2) during pediatric retroperitoneal laparoscopic surgery. This ongoing evaluation confirms the effect of laparoscopic urological surgery and CO(2) insufflation on cardiopulmonary function in children.