Laparoscopic cholecystectomy: haemodynamic and neuroendocrine responses after pneumoperitoneum and changes in position

Abstract

We have assessed the potential for myocardial ischaemia during laparoscopic cholecystectomy in 16 otherwise healthy patients. Continuous ambulatory ECG monitoring was commenced 12 h before operation and continued for 24 h after operation. The neuroendocrine stress response was assessed by measuring plasma concentrations of adrenaline and noradrenaline, human growth hormone, cortisol, renin and aldosterone, and prolactin, at specified times during surgery. Acute ST segment changes in the ECG occurred in only two patients. These episodes were independent of creation of pneumoperitoneum and changes in position. Acute intraoperative increases in MAP were noted during insufflation of carbon dioxide and reverse Trendelenburg positioning (P < 0.05). A four-fold increase in plasma concentrations of renin and aldosterone was noted after pneumoperitoneum and reverse Trendelenburg positioning (P > 0.05). There was a linear correlation between changes in plasma renin and aldosterone concentrations and MAP (r = 0.97 and r = 0.85, respectively). Prolactin concentrations increased four-fold after induction of anaesthesia. Cortisol, HGH, adrenaline and noradrenaline concentrations increased after deflation of the pneumoperitoneum. The time profile-concentration changes of increased MAP and renin-aldosterone suggests a cause-effect relationship. Increased intra-abdominal pressure and reverse Trendelenburg positioning may reduce cardiac output and renal blood flow. The early increase in prolactin concentration was probably secondary to the effect of the opioid fentanyl.

Effect of Different Carbon Dioxide Pressure Gradients in Capnoperitoneum for Laparoscopic Examination in Dogs

“…19 The ST intervals did not reveal any significant changes throughout the observation in three groups, however, ST elevation (in group A) and ST depression (in group C) were observed in some animals during post-CP and were suggestive of myocardial ischemia as a result of CP during laparoscopy. 20 PCV and Hb were unchanged throughout the observation period in all groups and remained within the normal range as also reported by Delling et al 21 24 hours after laparoscopy.…”

Novel insights into the neuroendocrinology of critical illness

“…It has been known for a long time that the vital stress-induced hypercortisolism induced by surgery, trauma or sepsis is associated with augmented adrenocorticotropin hormone (ACTH) release, which, in turn, is presumably driven by corticotropin-releasing hormone (CRH), cytokines and the noradrenergic system. Concomitantly, circulating aldosterone rises markedly, probably under the control of an activated renin±angiotensin system (80). Hypercortisolism acutely shifts carbohydrate, fat and protein metabolism, so that energy is instantly and selectively available to vital organs such as the brain and so that anabolism is delayed.…”

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

“…Alguns estudos observaram um aumento na concentração plasmática do hormônio antidiurético (ADH) após a criação do pneumoperitônio 40,50,51 , suficiente para determinar o aumento da PAM e da SVR por vasoconstrição 40,52,53 . Acriação do pneumoperitônio com a insuflação de CO 2 leva a um aumento da concentração plasmática da renina [54][55][56] e da aldosterona 55 e da noradrenalina. Um estudo não observou alterações significativas nas concentrações da epinefrina, da norepinefrina e na atividade da renina plasmática, que pudessem estar correlacionadas ao aumento da PAM 40 .…”

“…Some studies have observed increased plasma concentration of antidiuretic hormone (ADH) after pneumoperitoneum 40,50,51 , enough to determine increased MBP and SVR by vasoconstriction 40,52,53 . CO 2 pneumoperitoneum leads to increased rennin [54][55][56] , aldosterone 55 and norepinephrine plasma concentration. A study has not observed significant epinephrine and norepinephrine concentrations, and plasma rennin activity changes which could be related to increased MBP 40 .…”