Hemodynamic changes due to Trendelenburg positioning and pneumoperitoneum during laparoscopic hysterectomy

Abstract

More prolonged gynecological laparoscopic operations are being performed in recent years, and a steeper head-down position is required. The early reports of hemodynamic changes during gynecologic laparoscopy are conflicting, and the effects of anesthesia, head-down tilt and pneumoperitoneum have not been clearly separated. Invasive hemodynamic monitoring was carried out in 20 female ASA Class I-II patients who underwent laparoscopic hysterectomy. Baseline measurements were made in the supine, supine-lithotomy and Trendelenburg (25-30 degrees) positions in awake patients. Measurements were repeated in the supine-lithotomy and Trendelenburg positions after induction of anesthesia, during laparoscopy 5 minutes after the beginning of peritoneal CO2-insufflation (intra-abdominal pressure 13-16 mmHg) and at 15-minute intervals thereafter, after laparoscopy in the Trendelenburg and supine positions, after extubation and in the recovery room at 30-minute intervals. Patients received balanced general anesthesia with isoflurane in 35% O2 in an oxygen/air mixture. End tidal PCO2 was maintained between 4.5-4.8 kPa (33-36 mmHg) by changing the minute volume of controlled ventilation. The Trendelenburg position in awake and anesthetized patients increased pulmonary arterial pressures (PAP), central venous pressure (CVP) and pulmonary capillary wedge pressure (PCWP). These pressures increased further at the start of CO2-insufflation, decreased towards the end of the laparoscopy and reached pre-insufflation levels after deflation of pneumoperitoneum. The mean arterial pressure (MAP) increased at the beginning of laparoscopy in comparison with the pre-laparoscopic values. Heart rate (HR) was quite stable during laparoscopy. The cardiac index (CI) decreased with anesthesia from 3.8 to 3.2 1.min-1.m-2 and further during laparoscopy to 2.7 1.min-1.m-2, returning to pre-insufflation values soon after deflation. The stroke index (SI) changed in concert with the CI changes. The right ventricular stroke work index decreased during laparoscopy more than the left ventricular stroke work index. The right atrial pressure (CVP) exceeded the PCWP more often during laparoscopy than during any other phase of the procedure. Anesthesia and the Trendelenburg position increased the CVP, PCWP and pulmonary arterial pressures and decreased cardiac output. Pneumoperitoneum increased these pressures further mostly in the beginning of the laparoscopy, and cardiac output decreased towards the end of the laparoscopy. The risk of systemic CO2-embolus was increased during laparoscopy.

Pulse pressure variation and stroke volume variation predict fluid responsiveness in mechanically ventilated patients experiencing intra-abdominal hypertension

“…Russo et al demonstrated that headdown positioning was capable of increasing the venous return, enlarging left ventricular end-diastolic volume, and elevating the SV in normal and elevated IAP (21). Hirvonen et al demonstrated that the Trendelenburg position in awake and anesthetized patients increased pulmonary arterial pressures, CVP and pulmonary capillary wedge pressures, and these pressures further increased at the beginning of IAH (22). The elevated IAP influences the intrathoracic pressure by pushing the diaphragm upward, thus decreasing respiratory system compliance (23).…”

Estudo comparativo dos efeitos hemodinâmicos e ventilatórios da ventilação controlada a volume ou a pressão, em cães submetidos ao pneumoperitônio

“…Apesar da PCV ter sido estudada comparativamente na presença de doenças pulmonares, não foi encontrado estudo comparativo sobre o uso da PCV e da VCV em anestesia com o uso de pneumoperitônio, onde a complacência e a resistên-cia pulmonares sofrem alterações, mesmo que reversíveis ao fim do procedimento cirúrgico. Diversos estudos demonstraram que a freqüência cardíaca não sofre alterações significativas durante o pneumoperitô-nio [32][33][34][35][36][37][38][39][40][41] . O aumento da freqüência cardíaca foi similar nos dois grupos, após a aplicação do PPC, sem diferenças entre a ventilação com o controle do volume ou o controle da pressão.…”

“…Although PCV has been comparatively studied in the presence of pulmonary diseases, no comparative study was found on PCV and VCV in anesthesia with pneumoperitoneum, where pulmonary compliance and resistance are changed, even if reversible at the end of surgery. Several studies have shown that heart rate is not significantly changed during pneumoperitoneum [32][33][34][35][36][37][38][39][40][41] . Heart rate increase was similar for both groups after CPP without differences between volume controlled or pressure controlled ventilation.…”

Anaesthesia Management of a Patient with Incidentally Diagnosed Diaphragmatic Hernia During Laparoscopic Surgery

“…Bugüne kadar yapılan çalışmalarda, derin trendelenburg pozisyonu ve karbondioksit (CO 2 ) insüflasyonunun KAH ve ortalama arter basıncında (OAB) artış yaptığı bildirilmiştir (13). Kolesistektomi ve histerektominin tersine, laparoskopik kolon cerrahisi uzun anestezi ve cerrahi süresi gerektirmektedir (14).…”