Abstract
Although pneumoperitoneum has been well tolerated in a predominantly healthy population, there is concern that an increased intraperitoneal pressure may be poorly tolerated in patients with marginal cardiopulmonary function. The purpose of this study was to demonstrate noninvasively the hemodynamic effects of carbon dioxide pneumoperitoneum utilizing biplane transesophageal echocardiography.
Fourteen otherwise-healthy patients undergoing nonemergent laparoscopic cholecystectomy were studied using bi-plane transesophageal echocardiography under a standardized anesthetic protocol utilizing isoflurane, fentanyl, and vecuronium bromide. Endtidal CO2, oxygen saturation, cardiac rhythm, temperature, and blood pressure were monitored noninvasively. Minute ventilatory volume was adjusted as needed to keep end-tidal CO2 less than 38 mmHg. Data were recorded at baseline, following abdominal insufflation to 15 mmHg with CO2, with head-up tilt of 20°, following exsufflation, and with the patient level. Significance was determined using a paired Student t-test.
Insufflation to 15 mmHg decreased cardiac index (C.I.) by 3% (3.34 to 3.23 l/min/m2) while both heart rate (HR) and mean arterial pressure (MAP) increased (by 7% and 16%), respectively, and stroke volume index decreased by 10% (from 51.6 to 46.6 ml/beat/m2). Head-up tilt of 20° further decreased CI to 2.98 l/min/m2 (−11%) and SVI to 40.3 ml/beat/m2 (−22%) while HR increased by a total of 14% and MAP by 19%.
As laparoscopic techniques are applied to a broader population, the impact of small but significant decrements in cardiac function become increasingly important. This study demonstrates that the combination of CO2 pneumoperitoneum and the reverse Trendelenburg position does adversely effect cardiac output.
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Airan M, Appel M, Berci G, Coburg A, Cohen M, Cuschieri A, Dent T, Duppler D, Easter D, Greene F, Halevey A, Hammer S, Hunter J, Jenson M, Ko S, McFadyan B, Perissat J, Ponsky J, Ravindranathan P, Sackier J, Soper N, Van Stiegmann G, Traverso W, Udwadia T, Unger S, Wahlstrom E, Wolfe B (1992) Retrospective and prospective multi-institutional laparoscopic cholecystectomy study organized by the Society of American Gastrointestinal Endoscopic Surgeons. Surg Endosc 6: 169–176
Beaupre P, Cahalan M, Kremer P, Roizen M, Cronnelly R, Robinson S, Lurz F, Alpert R, Hamilton W, Schiller N (1983) Does pulmonary artery occlusion pressure adequately reflect left ventricular filling during anesthesia and surgery (Abstr)? Anesthesiology 59: A3
Brampton W, Watson R (1990) Arterial to end-tidal carbon dioxide tension difference during laparoscopy: magnitude and effect of anesthetic technique. Anaesthesiology 45: 210–214
Clements F, de Bruijn N (1991) Transesophageal echocardiography. Little, Brown and Company, Boston, pp 102–103
Doppman J, Rubinson R, Rockoff S, Vasko J, Shapiro R, Morrow A (1966) Mechanism of obstruction of the infradiaphragmatic portion of the inferior vena cava in the presence of increased intra-abdominal pressure. Invest Rad 1: 37–53
Ekman L, Abrahamsson J, Biber B, Forssman L, Milson I, Sjoqvist B (1988) Hemodynamic changes during laparoscopy with positive end-expiratory pressure ventilation. Acta Anaesthesiol Scand 32: 447–453
Folland E, Parisi A, Moynihan P, Jones D, Feldman C, Tow D (1979) Assessment of left ventricular ejection fraction and volumes by real-time, two-dimensional echocardiography: a comparison of cineangiographic and radionuclide techniques. Circulation 60: 760–766
Graff T, Arbegast N, Phillips O, Harris L, Frazier T (1959) Gas embolism: a comparative study of air and carbon dioxide as embolic agents in the systemic venous system. Am J Obstet Gynecol 78: 259–265
Harpole D, Clements F, Quill T, Wolfe W, Jones R, McCann R (1989) Right and left ventricular performance during and after abdominal aortic aneurysm repair. Ann Surg 209: 356–362
Johannsen F, Andersen M, Juhl B (1989) The effect of general anaesthesia on the haemodynamic events during laparoscopy with CO2-insufflation. Acta Anesthesiol Scand 33: 132–136
Kashtan J, Green J, Parsons E, Holcroft J (1981) Hemodynamic effects of increased abdominal pressure. J Surg Res 30: 249–255
Kelman G, Swapp G, Smith I, Benzie R, Gordon N (1972) Cardiac output and arterial blood-gas tension during laparoscopy. Br J Anaesthesiol 44: 1155–1161
Kent R, III (1991) Subcutaneous emphysema and hypercarbia following laparoscopic cholecystectomy. Arch Surg 126: 1154–1156
Lenhoff S, MacPhail B, Smith M, Kwan O, Booth D, Gurley J, DeMaria A (1991) Value and limitations of biplane transesophageal echo in the estimation of left ventricular volumes and ejection fraction (Abst). J Am Coll Cardiol 17: 35A
Lenz R, Thomas T, Wilkins D (1976) Cardiovascular changes during laparoscopy—studies of stroke volume and cardiac output using impedance cardiography. Anaesthesiology 31: 4–12
Litwin D, Girotti M, Poulin E, Mamazza J, Nagy A (1992) Laparoscopic cholecystectomy: trans-Canada experience with 2201 cases. Can J Surg 35: 291–296
McKenzie R, Wadhwa R, Bedger R (1980) Noninvasive measurement of cardiac output during laparoscopy. J Reprod Med 6: 247–250
Motew M, Ivankovich A, Bieniarz J, Albrecht R, Zahed B, Scommegna A (1973) Cardiovascular effects and acid-base and blood gas changes during laparoscopy. Am J Obstet Gynecol 115: 1002–1012
Rasmussen J, Dauchot P, DePalma R, Sorensen B, Regula G, Anton A, Gravenstein J (1978) Cardiac function and hypercarbia. Arch Surg 113: 1196–1200
Rubinson R, Vasko J, Doppman J, Morrow A (1967) Inferior vena caval obstruction from increased intra-abdominal pressure. Arch Surg 94: 766–770
Schiller N, Shah P, Crawford M, Demaria A, Devereux R, Feigenbaum H, Gutgesell H, Reichek N, Sahn D, Schnittger I, Silverman N (1989) Recommendations for quantitation of the left ventricle by two dimensional echocardiography. J Am Soc Echocardiogr 2: 358–367
Schiller N, Acquatella H, Ports T, Drew D, Goerke J, Ringertz H, Silverman N, Brundage B, Botvinick E, Boswell R, Carlsson E, Parmley W (1979) Left ventricular volume from paired biplane two-dimensional echocardiography. Circulation 60: 547–555
Spinale F, Reines H, Crawford F (1988) Comparison of bioimpedance and thermodilution methods for determining cardiac output: experimental and clinical studies. Ann Thorac Surg 45: 421–425
Van de Bos G, Drake A, Noble M (1979) The effect of carbon dioxide upon myocardial contractile performance, blood flow and oxygen consumption. J Physiol 287: 149–161
Versichelen L, Serreyn R, Rolly G, Vanderkerckhove D (1984) Physiopathologic changes during anesthesia administration for gynecologic laparoscopy. J Reprod Med 29: 697–700
Westerband A, Van de Water J, Amzallag M, Lebowitz P, Nwasokwa O, Chardavoyne R, Abou-Taleb A, Wang X, Wise L (1992) Cardiovascular changes during laparoscopic cholecystectomy. Surg Gynecol Obstet 175: 535–538
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Dorsay, D.A., Greene, F.L. & Baysinger, C.L. Hemodynamic changes during laparoscopic cholecystectomy monitored with transesophageal echocardiography. Surg Endosc 9, 128–134 (1995). https://doi.org/10.1007/BF00191952
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DOI: https://doi.org/10.1007/BF00191952