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Wittenborn J, Mathei D, van Waesberghe J, Zeppernick F, Zeppernick M, Tchaikovski S, Kowark A, Breuer M, Keszei A, Stickeler E, Zoremba N, Rossaint R, Bruells C, Meinhold-Heerlein I. The effect of warm and humidified gas insufflation in gynecological laparoscopy on maintenance of body temperature: a prospective randomized controlled multi-arm trial. Arch Gynecol Obstet 2022; 306:753-767. [PMID: 35286431 PMCID: PMC9411231 DOI: 10.1007/s00404-022-06499-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 02/26/2022] [Indexed: 11/29/2022]
Abstract
Background Hypothermia is defined as a decrease in body core temperature to below 36 °C. If intraoperative heat-preserving measures are omitted, a patient’s temperature will fall by 1 – 2 °C. Even mild forms of intraoperative hypothermia can lead to a marked increase in morbidity and mortality. Using warm and humidified gas insufflation in laparoscopy may help in the maintenance of intraoperative body temperature. Methods In this prospective randomized controlled study, we investigated effects of temperature and humidity of the insufflation gas on intra- and postoperative temperature management. 150 patients undergoing gynecologic laparoscopic surgery were randomly assigned to either insufflation with non-warmed, non-humidified CO2 with forced air warming blanket (AIR), humidified warm gas without forced air warming blanket (HUMI) or humidified warm gas combined with forced air warming blanket (HUMI+). We hypothesized that the use of warmed laparoscopic gas would have benefits in the maintenance of body temperature and reduce the occurrence of hypothermia. Results The use of warm and humidified gas insufflation alone led to more hypothermia episodes with longer duration and longer recovery times as well as significantly lower core body temperature compared to the other two groups. In the comparison of the AIR group and HUMI + group, HUMI + patients had a significantly higher body temperature at arrival at the PACU (Post Anaesthesia Care Unit), had the least occurrence of hypothermia and suffered from less shivering. Conclusion The use of warm and humidified gas insufflation alone does not sufficiently warm the patients. The optimal temperature management is achieved in the combination of external forced air warming and insufflation of warm and humidified laparoscopy gas. Supplementary Information The online version contains supplementary material available at 10.1007/s00404-022-06499-z.
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Affiliation(s)
- Julia Wittenborn
- Department of Gynecology and Obstetrics, University Hospital of the RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany.
| | - Deborah Mathei
- Department of Gynecology and Obstetrics, University Hospital of the RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Julia van Waesberghe
- Department of Anesthesiology, University Hospital of the RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Felix Zeppernick
- Department of Gynecology and Obstetrics, University Hospital of Gießen and Marburg, Justus-Liebig University Gießen, Klinikstr. 33, 35392, Giessen, Germany
| | - Magdalena Zeppernick
- Department of Gynecology and Obstetrics, University Hospital of Gießen and Marburg, Justus-Liebig University Gießen, Klinikstr. 33, 35392, Giessen, Germany
| | - Svetlana Tchaikovski
- Department of Gynecology and Obstetrics, University Hospital of the RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Ana Kowark
- Department of Anesthesiology, University Hospital of the RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Markus Breuer
- Department of Anesthesiology, University Hospital of the RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - András Keszei
- Department of Medical Statistics, University Hospital of the RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Elmar Stickeler
- Department of Gynecology and Obstetrics, University Hospital of the RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Norbert Zoremba
- Department of Anesthesiology and Intensive Care, St Elisabeth Hospital, Stadtring Kattenstroth 130, 33332, Gütersloh, Germany
| | - Rolf Rossaint
- Department of Anesthesiology, University Hospital of the RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Christian Bruells
- Department of Anesthesiology, University Hospital of the RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Ivo Meinhold-Heerlein
- Department of Gynecology and Obstetrics, University Hospital of the RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany.,Department of Gynecology and Obstetrics, University Hospital of Gießen and Marburg, Justus-Liebig University Gießen, Klinikstr. 33, 35392, Giessen, Germany
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Breuer M, Wittenborn J, Rossaint R, Van Waesberghe J, Kowark A, Mathei D, Keszei A, Tchaikovski S, Zeppernick M, Zeppernick F, Stickeler E, Zoremba N, Meinhold-Heerlein I, Bruells C. Warm and humidified insufflation gas during gynecologic laparoscopic surgery reduces postoperative pain in predisposed patients-a randomized, controlled multi-arm trial. Surg Endosc 2022; 36:4154-4170. [PMID: 34596747 PMCID: PMC9085687 DOI: 10.1007/s00464-021-08742-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 09/20/2021] [Indexed: 01/29/2023]
Abstract
BACKGROUND Postoperative pain remains a common problem in gynecologic laparoscopy, especially in head zone-related regions, triggered by intra-abdominal pressure during capnoperitoneum. Humidified and prewarmed insufflation gas may ameliorate pain and be beneficial. METHODS This prospective randomized controlled parallel group multi-arm single-center study investigated the effects of temperature and humidity of insufflation gas on postoperative pain during gynecologic laparoscopy with a duration ≥ 60 min. Female participants (18-70 years) were blinded and randomly assigned-computer generated-to either insufflation with dry cold CO2 with forced air warming blanket ("AIR"), humidified warm gas without forced air warming blanket ("HUMI"), or humidified warm gas with forced air warming blanket ("HUMI +"). We hypothesized that using humidified warm gas resulted in lower pain scores and less analgesic consumption. The primary endpoint postoperative pain was assessed for different pain localizations every 12 h during 7 days after surgery. Secondary endpoints were demand for painkillers and epidural anesthetics, length of stay in recovery room, and hospital stay. (Registration: ClinicalTrials.gov NCT02781194-completed). RESULTS 150 participants were randomized. Compared to group "AIR" (n = 48), there was significantly less pain in group "HUMI +" (n = 48) in the recovery room (- 1.068; 95% CI - 2.08 to - 0.061), as well as significantly less ibuprofen use at day two (- 0.5871 g ± 0.258; p-value = 0.0471). Other variables did not change significantly. Stratification for presence of endometriosis or non-previous abdominal surgery in patient history revealed significantly less pain in both groups "HUMI" (n = 50) and "HUMI +" versus group "AIR." Related side effects were not noted. CONCLUSION In the overall population, the use of warm, humidified insufflation gas did not yield clinically relevant effects; however, in predisposed patients with endometriosis and who could otherwise expect high pain levels, warm and humidified gas may be beneficial.
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Affiliation(s)
- Markus Breuer
- grid.412301.50000 0000 8653 1507Department of Anesthesiology, University Hospital of the RWTH Aachen, Pauwelsstrasse 30, 52074 Aachen, Germany
| | - Julia Wittenborn
- grid.412301.50000 0000 8653 1507Department of Gynecology and Obstetrics, University Hospital of the RWTH Aachen, Pauwelsstrasse 30, 52074 Aachen, Germany
| | - Rolf Rossaint
- grid.412301.50000 0000 8653 1507Department of Anesthesiology, University Hospital of the RWTH Aachen, Pauwelsstrasse 30, 52074 Aachen, Germany
| | - Julia Van Waesberghe
- grid.412301.50000 0000 8653 1507Department of Anesthesiology, University Hospital of the RWTH Aachen, Pauwelsstrasse 30, 52074 Aachen, Germany
| | - Ana Kowark
- grid.412301.50000 0000 8653 1507Department of Anesthesiology, University Hospital of the RWTH Aachen, Pauwelsstrasse 30, 52074 Aachen, Germany
| | - Deborah Mathei
- grid.412301.50000 0000 8653 1507Department of Gynecology and Obstetrics, University Hospital of the RWTH Aachen, Pauwelsstrasse 30, 52074 Aachen, Germany
| | - András Keszei
- grid.412301.50000 0000 8653 1507Department of Medical Statistics, University Hospital of the RWTH Aachen, Pauwelsstrasse 30, 52074 Aachen, Germany
| | - Svetlana Tchaikovski
- grid.412301.50000 0000 8653 1507Department of Gynecology and Obstetrics, University Hospital of the RWTH Aachen, Pauwelsstrasse 30, 52074 Aachen, Germany
| | - Magdalena Zeppernick
- grid.412301.50000 0000 8653 1507Department of Gynecology and Obstetrics, University Hospital of the RWTH Aachen, Pauwelsstrasse 30, 52074 Aachen, Germany ,grid.8664.c0000 0001 2165 8627Department of Gynecology and Obstetrics, University Hospital of Gießen and Marburg, Justus-Liebig University Gießen, Klinikstr. 33, 35392 Giessen, Germany
| | - Felix Zeppernick
- grid.412301.50000 0000 8653 1507Department of Gynecology and Obstetrics, University Hospital of the RWTH Aachen, Pauwelsstrasse 30, 52074 Aachen, Germany ,grid.8664.c0000 0001 2165 8627Department of Gynecology and Obstetrics, University Hospital of Gießen and Marburg, Justus-Liebig University Gießen, Klinikstr. 33, 35392 Giessen, Germany
| | - Elmar Stickeler
- grid.412301.50000 0000 8653 1507Department of Gynecology and Obstetrics, University Hospital of the RWTH Aachen, Pauwelsstrasse 30, 52074 Aachen, Germany
| | - Norbert Zoremba
- grid.416619.d0000 0004 0636 2627Department of Anesthesiology and Intensive Care, St Elisabeth Hospital, Stadtring Kattenstroth 130, 33332 Gütersloh, Germany
| | - Ivo Meinhold-Heerlein
- grid.412301.50000 0000 8653 1507Department of Gynecology and Obstetrics, University Hospital of the RWTH Aachen, Pauwelsstrasse 30, 52074 Aachen, Germany ,grid.8664.c0000 0001 2165 8627Department of Gynecology and Obstetrics, University Hospital of Gießen and Marburg, Justus-Liebig University Gießen, Klinikstr. 33, 35392 Giessen, Germany
| | - Christian Bruells
- grid.412301.50000 0000 8653 1507Department of Anesthesiology, University Hospital of the RWTH Aachen, Pauwelsstrasse 30, 52074 Aachen, Germany
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Amberg BJ, Hodges RJ, Rodgers KA, Crossley KJ, Hooper SB, DeKoninck PLJ. Why Do the Fetal Membranes Rupture Early after Fetoscopy? A Review. Fetal Diagn Ther 2021; 48:493-503. [PMID: 34404043 DOI: 10.1159/000517151] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 05/03/2021] [Indexed: 11/19/2022]
Abstract
Iatrogenic preterm premature rupture of the fetal membranes (iPPROM) remains the Achilles' heel of keyhole fetal surgery (fetoscopy) despite significant efforts in preclinical models to develop new therapies. This limited success is partially due to incomplete understanding why the fetal membranes rupture early after fetoscopy and notable differences in membrane physiology between humans and domestic species. In this review, we summarize aspects of fetoscopy that may contribute to iPPROM, the previous efforts to develop new therapies, and limitations of preclinical models commonly used in fetal membrane research.
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Affiliation(s)
- Benjamin J Amberg
- The Department of Obstetrics and Gynaecology, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia, .,The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia,
| | - Ryan J Hodges
- The Department of Obstetrics and Gynaecology, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia.,The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
| | - Karyn A Rodgers
- The Department of Obstetrics and Gynaecology, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia.,The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
| | - Kelly J Crossley
- The Department of Obstetrics and Gynaecology, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia.,The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
| | - Stuart B Hooper
- The Department of Obstetrics and Gynaecology, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia.,The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
| | - Philip L J DeKoninck
- The Department of Obstetrics and Gynaecology, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia.,The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
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Amberg BJ, DeKoninck PLJ, Kashyap AJ, Skinner SM, Rodgers KA, McGillick EV, Deprest JA, Hooper SB, Crossley KJ, Hodges RJ. Placental gas exchange during amniotic carbon dioxide insufflation in sheep. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 57:305-313. [PMID: 31765050 DOI: 10.1002/uog.21933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 11/14/2019] [Accepted: 11/15/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE Insufflation of the amniotic cavity with carbon dioxide (CO2 ) is used clinically to improve visibility during complex fetoscopic surgery. Insufflation with heated, humidified CO2 has recently been shown to reduce fetal hypercapnia and acidosis in sheep, compared with use of cold and dry CO2 , but the underlying mechanisms are unclear. The aim of this study was to investigate whether differences in placental CO2 and oxygen (O2 ) exchange during insufflation with heated and humidified vs cold and dry CO2 could explain these findings. METHODS Thirteen fetal lambs at 105 days of gestation (term, 146 days) were exteriorized partially, via a midline laparotomy and hysterotomy, and instrumented with an umbilical artery catheter, an umbilical vein catheter and a common umbilical vein flow probe. Arterial and venous catheters and flow probes were also inserted into the maternal uterine circulation. Six ewes were insufflated with cold, dry CO2 (22°C; 0-5% humidity) and seven with heated, humidified CO2 (40°C; 95-100% humidity) at 15 mmHg for 180 min. Blood-flow recordings and paired arterial and venous blood gases were sampled from uterine and umbilical vessels. Rates of placental CO2 and O2 exchange were calculated. RESULTS After 180 min of insufflation, fetal survival was 33% (2/6) using cold, dry CO2 and 71% (5/7) using heated, humidified CO2 . By 120 min, fetuses insufflated with heated, humidified CO2 had lower arterial CO2 levels and higher arterial pH compared to those insufflated with cold, dry gas. Insufflation decreased significantly placental gas exchange in both groups, as measured by rates of both (i) fetal CO2 clearance and O2 uptake and (ii) maternal O2 delivery and CO2 uptake from the fetal compartment. CONCLUSIONS Lower arterial CO2 and higher pH levels in fetuses insufflated with heated and humidified, compared to cold and dry, CO2 could not be explained by differences in placental gas exchange. Instead, heated and humidified insufflation appeared to reduce fetal CO2 absorption from the uterus, supporting its use in preference to cold, dry CO2 . © 2019 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- B J Amberg
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - P L J DeKoninck
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - A J Kashyap
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - S M Skinner
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
| | - K A Rodgers
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
| | - E V McGillick
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - J A Deprest
- Department of Obstetrics and Gynaecology, Division Woman and Child, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, Cluster Organ Systems, Faculty of Medicine, KU Leuven, Leuven, Belgium
| | - S B Hooper
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - K J Crossley
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - R J Hodges
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
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5
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Amberg BJ, Hodges RJ, Kashyap AJ, Skinner SM, Rodgers KA, McGillick EV, Deprest JA, Hooper SB, Crossley KJ, DeKoninck PLJ. Physiological effects of partial amniotic carbon dioxide insufflation with cold, dry vs heated, humidified gas in a sheep model. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 53:340-347. [PMID: 30461102 PMCID: PMC6635737 DOI: 10.1002/uog.20180] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 10/30/2018] [Accepted: 11/09/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVE Partial amniotic carbon dioxide (CO2 ) insufflation (PACI) is used to improve visualization and facilitate complex fetoscopic surgery. However, there are concerns about fetal hypercapnic acidosis and postoperative fetal membrane inflammation. We assessed whether using heated and humidified, rather than cold and dry, CO2 might reduce the impact of PACI on the fetus and fetal membranes in sheep. METHODS Twelve fetal lambs of 105 days' gestational age (term = 145 days) were exteriorized partially, via a midline laparotomy and hysterotomy, and arterial catheters and flow probes were inserted surgically. The 10 surviving fetuses were returned to the uterus, which was then closed and insufflated with cold, dry (22 °C at 0-5% humidity, n = 5) or heated, humidified (40 °C at 100% humidity, n = 5) CO2 at 15 mmHg for 180 min. Fetal membranes were collected immediately after insufflation for histological analysis. Physiological data and membrane leukocyte counts, suggestive of membrane inflammation, were compared between the two groups. RESULTS After 180 min of insufflation, fetal survival was 0% in the group which underwent PACI with cold, dry CO2 , and 60% (n = 3) in the group which received heated, humidified gas. While all insufflated fetuses became progressively hypercapnic (PaCO2 > 68 mmHg), this was considerably less pronounced in those in which heated, humidified gas was used: after 120 min of insufflation, compared with those receiving cold, dry gas (n = 3), fetuses undergoing heated, humidified PACI (n = 5) had lower arterial partial pressure of CO2 (mean ± standard error of the mean, 82.7 ± 9.1 mmHg for heated, humidified CO2 vs 170.5 ± 28.5 for cold, dry CO2 during PACI, P < 0.01), lower lactate levels (1.4 ± 0.4 vs 8.5 ± 0.9 mmol/L, P < 0.01) and higher pH (pH, 7.10 ± 0.04 vs 6.75 ± 0.04, P < 0.01). There was also a non-significant trend for fetal carotid artery pressure to be higher following PACI with heated, humidified compared with cold, dry CO2 (30.5 ± 1.3 vs 8.7 ± 5.5 mmHg, P = 0.22). Additionally, the median (interquartile range) number of leukocytes in the chorion was significantly lower in the group undergoing PACI with heated, humidified CO2 compared with the group receiving cold, dry CO2 (0.7 × 10-5 (0.5 × 10-5 ) vs 3.2 × 10-5 (1.8 × 10-5 ) cells per square micron, P = 0.02). CONCLUSIONS PACI with cold, dry CO2 causes hypercapnia, acidosis, hypotension and fetal membrane inflammation in fetal sheep, raising potential concerns for its use in humans. It seems that using heated, humidified CO2 for insufflation partially mitigates these effects and this may be a suitable alternative for reducing the risk of fetal acid-base disturbances during, and fetal membrane inflammation following, complex fetoscopic surgery. © 2018 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- B. J. Amberg
- The Ritchie Centre, Hudson Institute of Medical ResearchMelbourneVictoriaAustralia
- Department of Obstetrics and GynaecologyMonash UniversityMelbourneVictoriaAustralia
| | - R. J. Hodges
- The Ritchie Centre, Hudson Institute of Medical ResearchMelbourneVictoriaAustralia
- Department of Obstetrics and GynaecologyMonash UniversityMelbourneVictoriaAustralia
| | - A. J. Kashyap
- The Ritchie Centre, Hudson Institute of Medical ResearchMelbourneVictoriaAustralia
| | - S. M. Skinner
- The Ritchie Centre, Hudson Institute of Medical ResearchMelbourneVictoriaAustralia
| | - K. A. Rodgers
- The Ritchie Centre, Hudson Institute of Medical ResearchMelbourneVictoriaAustralia
| | - E. V. McGillick
- The Ritchie Centre, Hudson Institute of Medical ResearchMelbourneVictoriaAustralia
- Department of Obstetrics and GynaecologyMonash UniversityMelbourneVictoriaAustralia
| | - J. A. Deprest
- Institute of Woman's HealthUniversity College LondonLondonUK
- Department of Development and Regeneration, Cluster Organ Systems, Faculty of MedicineKU LeuvenLeuvenBelgium
| | - S. B. Hooper
- The Ritchie Centre, Hudson Institute of Medical ResearchMelbourneVictoriaAustralia
- Department of Obstetrics and GynaecologyMonash UniversityMelbourneVictoriaAustralia
| | - K. J. Crossley
- The Ritchie Centre, Hudson Institute of Medical ResearchMelbourneVictoriaAustralia
- Department of Obstetrics and GynaecologyMonash UniversityMelbourneVictoriaAustralia
| | - P. L. J. DeKoninck
- The Ritchie Centre, Hudson Institute of Medical ResearchMelbourneVictoriaAustralia
- Department of Obstetrics and GynaecologyMonash UniversityMelbourneVictoriaAustralia
- Department of Obstetrics and GynaecologyErasmus MC‐Sophia Children's HospitalRotterdamThe Netherlands
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Marshall JK, Tait N, van der Linden J. Laparotomy causes loss of peritoneal mesothelium prevented by humidified CO2 insufflation in rats. J Surg Res 2017; 220:300-310. [DOI: 10.1016/j.jss.2017.06.057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 06/02/2017] [Accepted: 06/16/2017] [Indexed: 11/16/2022]
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Five year follow-up of a randomized controlled trial on warming and humidification of insufflation gas in laparoscopic colonic surgery--impact on small bowel obstruction and oncologic outcomes. Int Surg 2016; 100:608-16. [PMID: 25875541 DOI: 10.9738/intsurg-d-14-00210.1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Warming and humidification of insufflation gas has been shown to reduce adhesion formation and tumor implantation in the laboratory setting, but clinical evidence is lacking. We aimed to test the hypothesis that warming and humidification of insufflation CO2 would lead to reduced adhesion formation, and improve oncologic outcomes in laparoscopic colonic surgery. This was a 5-year follow-up of a multicenter, double-blinded, randomized, controlled trial investigating warming and humidification of insufflation gas. The study group received warmed (37°C), humidified (98%) insufflation carbon dioxide, and the control group received standard gas (19°C, 0%). All other aspects of patient care were standardized. Admissions for small bowel obstruction were recorded, as well as whether management was operative or nonoperative. Local and systemic cancer recurrence, 5-year overall survival, and cancer specific survival rates were also recorded. Eighty two patients were randomized, with 41 in each arm. Groups were well matched at baseline. There was no difference between the study and control groups in the rate of clinical small bowel obstruction (5.7% versus 0%, P 0.226); local recurrence (6.5% versus 6.1%, P 1.000); overall survival (85.7% versus 82.1%, P 0.759); or cancer-specific survival (90.3% versus 87.9%, P 1.000). Warming and humidification of insufflation CO2 in laparoscopic colonic surgery does not appear to confer a clinically significant long term benefit in terms of adhesion reduction or oncological outcomes, although a much larger randomized controlled trial (RCT) would be required to confirm this. ClinicalTrials.gov Trial identifier: NCT00642005; US National Library of Medicine, 8600 Rockville Pike, Bethesda, MD 20894, USA.
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Mason SE, Kinross JM, Hendricks J, Arulampalam TH. Postoperative hypothermia and surgical site infection following peritoneal insufflation with warm, humidified carbon dioxide during laparoscopic colorectal surgery: a cohort study with cost-effectiveness analysis. Surg Endosc 2016; 31:1923-1929. [PMID: 27734204 PMCID: PMC5346131 DOI: 10.1007/s00464-016-5195-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Accepted: 08/17/2016] [Indexed: 11/30/2022]
Abstract
Background Surgical Site Infection (SSI) occurs in 9 % of laparoscopic colorectal surgery. Warming and humidifying carbon dioxide (CO2) used for peritoneal insufflation may protect against SSI by avoiding postoperative hypothermia (itself a risk factor for SSI). This study aimed to assess the impact of CO2 conditioning on postoperative hypothermia and SSI and to perform a cost-effectiveness analysis. Methods A retrospective cohort study of patients undergoing elective laparoscopic colorectal resection was performed at a single UK specialist centre. The control group (n = 123) received peritoneal insufflation with room temperature, dry CO2, whereas the intervention group (n = 123) received warm, humidified CO2 (using HumiGard™, Fisher & Paykel Healthcare). The outcomes were postoperative hypothermia, SSI and costs. Multivariate analysis was performed. Results A total of 246 patients were included in the study. The mean age was 68 (20–87) and mean BMI 28 (15–51). The primary diagnosis was cancer (n = 173), and there were no baseline differences between the groups. CO2 conditioning significantly decreased the incidence of postoperative hypothermia (odds ratio 0.10, 95 % CI 0.04–0.23), with hypothermic patients found to be at increased risk of SSI (odds ratio 4.0, 95 % CI 1.25–12.9). Use of conditioned CO2 significantly decreased the incidence of SSI by 66 % (p = 0.04). The intervention group incurred costs of £155 less per patient. The incremental cost-effectiveness ratio was negative. Conclusion CO2 conditioning during laparoscopic colorectal surgery is a safe, feasible and a cost-effective intervention. It improves the quality of surgical care relating to SSI and postoperative hypothermia.
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Affiliation(s)
- Sam E Mason
- ICENI Centre, Colchester Hospital, Turner Road, Colchester, Essex, CO4 5JL, UK.
| | - James M Kinross
- ICENI Centre, Colchester Hospital, Turner Road, Colchester, Essex, CO4 5JL, UK.,Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, London, UK
| | - Jane Hendricks
- ICENI Centre, Colchester Hospital, Turner Road, Colchester, Essex, CO4 5JL, UK
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Marshall JK, Lindner P, Tait N, Maddocks T, Riepsamen A, van der Linden J. Intra-operative tissue oxygen tension is increased by local insufflation of humidified-warm CO2 during open abdominal surgery in a rat model. PLoS One 2015; 10:e0122838. [PMID: 25835954 PMCID: PMC4383325 DOI: 10.1371/journal.pone.0122838] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Accepted: 02/20/2015] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION Maintenance of high tissue oxygenation (PtO2) is recommended during surgery because PtO2 is highly predictive of surgical site infection and colonic anastomotic leakage. However, surgical site perfusion is often sub-optimal, creating an obstructive hurdle for traditional, systemically applied therapies to maintain or increase surgical site PtO2. This research tested the hypothesis that insufflation of humidified-warm CO2 into the abdominal cavity would increase sub-peritoneal PtO2 during open abdominal surgery. MATERIALS AND METHODS 15 Wistar rats underwent laparotomy under general anesthesia. Three sets of randomized cross-over experiments were conducted in which the abdominal cavity was subjected to alternating exposure to 1) humidified-warm CO2 & ambient air; 2) humidified-warm CO2 & dry-cold CO2; and 3) dry-cold CO2 & ambient air. Sub-peritoneal PtO2 and tissue temperature were measured with a polarographic oxygen probe. RESULTS Upon insufflation of humidified-warm CO2, PtO2 increased by 29.8 mmHg (SD 13.3; p<0.001), or 96.6% (SD 51.9), and tissue temperature by 3.0°C (SD 1.7 p<0.001), in comparison with exposure to ambient air. Smaller, but significant, increases in PtO2 were seen in experiments 2 and 3. Tissue temperature decreased upon exposure to dry-cold CO2 compared with ambient air (-1.4°C, SD 0.5, p = 0.001). CONCLUSIONS In a rat model, insufflation of humidified-warm CO2 into the abdominal cavity during open abdominal surgery causes an immediate and potentially clinically significant increase in PtO2. The effect is an additive result of the delivery of CO2 and avoidance of evaporative cooling via the delivery of the CO2 gas humidified at body temperature.
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Affiliation(s)
- Jean K. Marshall
- Illawarra Health and Medical Research Institute, University of Wollongong, Wollongong, Australia
- Graduate School of Medicine, University of Wollongong, Wollongong, Australia
- * E-mail:
| | - Pernilla Lindner
- Karolinska Institute, Department of Cardiothoracic Surgery and Anesthesiology, Karolinska University Hospital, Stockholm, Sweden
| | - Noel Tait
- Moruya District Hospital, Moruya, Australia
| | - Tracy Maddocks
- Illawarra Health and Medical Research Institute, University of Wollongong, Wollongong, Australia
| | - Angelique Riepsamen
- School of Women’s & Children’s Health, University of New South Wales, Sydney, Australia
| | - Jan van der Linden
- Karolinska Institute, Department of Cardiothoracic Surgery and Anesthesiology, Karolinska University Hospital, Stockholm, Sweden
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Insufflation with humidified and heated carbon dioxide in short-term laparoscopy: a double-blinded randomized controlled trial. BIOMED RESEARCH INTERNATIONAL 2015; 2015:412618. [PMID: 25722977 PMCID: PMC4324813 DOI: 10.1155/2015/412618] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 01/07/2015] [Indexed: 11/18/2022]
Abstract
Background. We tested the hypothesis that warm-humidified carbon dioxide (CO2) insufflation would reduce postoperative pain and morphine requirement compared to cold-dry CO2 insufflation. Methods. A double-blinded, randomized, controlled trial was conducted to compare warm, humidified CO2 and cold-dry CO2. Patients with benign uterine diseases were randomized to either treatment (n = 48) or control (n = 49) group during laparoscopically assisted vaginal hysterectomy. Primary endpoints of the study were rest pain, movement pain, shoulder-tip pain, and cough pain at 2, 4, 6, 24, and 48 hours postoperatively, measured by visual analogue scale. Secondary outcomes were morphine consumption, rejected boli, temperature change, recovery room stay, and length of hospital stay. Results. There were no significant differences in all baseline characteristics. Shoulder-tip pain at 6 h postoperatively was significantly reduced in the intervention group. Pain at rest, movement pain, and cough pain did not differ. Total morphine consumption and rejected boli at 24 h postoperatively were significantly higher in the control group. Temperature change, recovery room stay, and length of hospital were similar. Conclusions. Warm, humidified insufflation gas significantly reduces postoperative shoulder-tip pain as well as morphine demand. This trial is registered with Clinical Trial Registration Number
DRKS00003853 (German Clinical Trials Register (DRKS)).
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The effects of insufflation conditions on rat mesothelium. Int J Inflam 2013; 2013:816283. [PMID: 23864985 PMCID: PMC3707227 DOI: 10.1155/2013/816283] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2013] [Revised: 06/11/2013] [Accepted: 06/11/2013] [Indexed: 11/18/2022] Open
Abstract
Aim. The aim of this investigation was to examine the alterations in the peritoneum after cold dry CO2, heated dry CO2, and humidified heated CO2 at pressures equivalent to intraperitoneal pressures used in human laparoscopy. Methods. Eighteen rats were divided into 4 treatment groups—group 1: untreated control; group 2: insufflation with cold dry CO2; group 3: insufflation with heated, dry CO2; group 4: insufflation with heated and humidified CO2. The abdomen was insufflated to 5 mm/Hg (flow rate 50 mL/min) for 2 h. Twelve hours later, tissue samples were collected for analysis by light microscopy (LM) and scanning electron microscopy (SEM). Results. Group 1: no abnormalities were detected. Group 2: specimens revealed an inflammatory response with loss of mesothelium and mesothelial cell nuclei showing lytic change. Cells were rounded with some areas of cell flattening and separation. Group 3: some animals showed little or no alteration, while others had a mild inflammatory response. Mesothelial cells were rounded and showed crenation on the exposed surface. Group 4: specimens showed little change from the control group. Conclusions. The LM results indicate that insufflations with heated, humidified CO2 are the least likely to induce mesothelial damage.
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Warm, humidified carbon dioxide gas insufflation for laparoscopic appendicectomy in children: a double-blinded randomized controlled trial. Ann Surg 2013; 257:44-53. [PMID: 22824858 DOI: 10.1097/sla.0b013e31825f0721] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To investigate clinical benefits of warm, humidified carbon dioxide (CO(2)) insufflation for acute laparoscopic appendicectomy on postoperative pain and recovery in children (age 8-14 years). BACKGROUND Conventional CO(2) insufflation leads to desiccation-related peritoneal inflammation and injury, which is preventable with warm, humidified CO2 gas. We hypothesized that reduced peritoneal desiccation would improve patient-centered outcomes in children after laparoscopic appendicectomy. METHOD A double-blinded, randomized controlled trial was conducted. Intervention group participants received warm (37°C), humidified (98% relative humidity) CO(2) gas insufflation, whereas control participants received standard room temperature (20°C) gas with 0% relative humidity. Perioperative analgesia and anesthesia were standardized. Postoperative opiate usage was converted to morphine equivalent daily dosages (MEDD) for comparison, and pain intensity at rest and on moving was rated by participants using visual analog scales. Postoperative recovery and return to normal activities was assessed using a questionnaire on day 10. RESULTS Between February 2010 and March 2011, a total of 190 participants were randomized. Both intervention and control groups were matched at baseline. Postoperative MEDD and pain scores were also similar. There were no differences in postoperative recovery parameters. CONCLUSIONS Warm, humidified CO(2) insufflation for acute laparoscopic appendicectomy has no short-term clinical benefits on postoperative outcomes in pediatric patients (ClinicalTrials.gov trial identifying code: NCT01027455).
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Heat loss during carbon dioxide insufflation: comparison of a nebulization based humidification device with a humidification and heating system. Surg Endosc 2012; 26:3622-5. [DOI: 10.1007/s00464-012-2385-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2011] [Accepted: 05/14/2012] [Indexed: 11/26/2022]
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