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ORIGINAL ARTICLE
Year : 2008  |  Volume : 2  |  Issue : 2  |  Page : 62-66

Five hours of insufflation in a bad position: Anaesthetic implications


1 Department of Anesthesia, Faculty of Medicine , Mansoura University, Mansoura, Egypt
2 Department of Urology, Faculty of Medicine , Mansoura University, Mansoura, Egypt

Correspondence Address:
A A Shorrab
Department of Anesthesia, Faculty of Medicine , Mansoura University, Mansoura
Egypt
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Source of Support: None, Conflict of Interest: None


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Date of Web Publication18-Jul-2009
 

   Abstract 

Background. Laparoscopic radical cystectomy is a relatively new surgical procedure. Being a procedure of long duration, performed with pneumoperitoneum in exaggerated Trendlenberg position; it is expectedtopose unfavorable effects. We report pulmonary and haemodynamic changes in addition to postoperative outcome following laparoscopic radical cystectomy.
Patients and Methods. The study was conducted on 31 patients anaesthetized with a combination of epidural and total intravenous anaesthesia (using midazolam, fentanyl, ketamine and vecuronium). Surgery wasdone while the patient in head down position (40 o ). Lungs were ventilated using air-oxygen (FiO2 = 0.35) with a tidal volume of 8 ml kg -1 at a rate of 12-14 min -1 . Lung mechanics and hemodynamic variables were recorded at different strategic points. Recovery and postoperative outcome were also evaluated.
Results. Two patients were excluded due to conversion to open surgery and 29 completed the procedure. Fourteen of 29 patients (48.2%) had preoperative medical diseases and 11 patients (38%) received blood. There were significant decrease in lung compliance and significant increase in peak pressures after pneumoperitoneum and Trendlenberg position. Concomitantly, heart rate, arterial pressure and carbondioxide tension increased significantly. Three patients suffered post-extubation airway obstruction and the trachea was re-intubated. On the first postoperative day, one patient desaturated and one patient suffered severe nausea and vomiting.
Conclusions. Laparoscopic radical cystectomy in exaggerated head down position may be associated with harmful consequences and potential risks.

Keywords: Intravenous anesthesia; Laparoscopic radical cystectomy; Complications.


How to cite this article:
Shorrab A A, Demian A D, Shoma A M, Banoub S M. Five hours of insufflation in a bad position: Anaesthetic implications. Saudi J Anaesth 2008;2:62-6

How to cite this URL:
Shorrab A A, Demian A D, Shoma A M, Banoub S M. Five hours of insufflation in a bad position: Anaesthetic implications. Saudi J Anaesth [serial online] 2008 [cited 2019 Oct 17];2:62-6. Available from: http://www.saudija.org/text.asp?2008/2/2/62/51858


   Introduction Top


WITH ADVANCES IN LAPAROSCOPIC technology and more experience of urologists in this technique, laparoscopic surgery has been performed successfully in many urological procedures. These included radical [1] and donor nephrectomy [2] , adrenalectomy for pheochromocytoma [3] , simple nephrectomy in end stage renal failure [4] , radical prostatectomy [5] and-recently-radical cystectomy and urinary diversion [6],[7] . The advantages of this technique is that laparoscopic techniques are associated with less blood loss, less pain, lower incidence of postoperative illeus, shorter hospital stay and quicker return to normal activities compared to conventional open surgery [8] .

Laparoscopic trans-peritoneal radical cystectomy is a new major surgery often performed on male, smoker patients with mild to moderate systemic diseases. In addition, insufflation of CO 2 is associated with hemodynamic [9],[10],[11] and respiratory effects which are further exaggerated by head-down position [12] . These changes may compromise cardiac and pulmonary functions particularly in elderly or obese patients with limited reserve. The initial results of total intravenous anesthesia (TIVA) using ketamine and midazolam in open radical cystectomy proved satisfactory [13] .

We report the outcome of laparoscopic radical cystectomy under TIVA in exaggerated head-down position. Pulmonary and hemodynamic changes were the primary outcome and peri-operative adverse events were the secondary outcome.


   Patients and Methods Top


This prospective study was conducted on 31 patients (ASA I - II) with cancer bladder undergoing laparoscopic radical cystectomy in Urology and Nephrology Centre, Mansoura University. Exclusion criteria included major organ diseases affecting the physical status; cerebral cardio-pulmonary, hepatic dysfunction or uncontrolled diabetes mellitus. The protocol was approved by our centre research ethics committee and a written informed consent was obtained from every patient. Single-shot lumbar epidural anaesthesia was conducted in all patients by administration of 10 ml bupivacaine 0.25% mixed with 2 mg morphine given via L2-3 or L3-4. Central venous cannulation (CVP) was done under local lidocaine through internal jugular approach and arterial cannula was fixed for invasive arterial blood pressure monitoring. Anesthesia was induced by fentanyl (2 µg kg -1 ), midazolam (0.1 mg kg -1 ) and ketamine (2 mg kg -1 ). Vecuronium (0.12 mg kg -1 ) was used to facilitate tracheal intubation and to maintain muscle relaxation during surgery. Anesthesia was maintained in the first hour by intravenous infusion of ketamine (30 µg kg-1 m-1 ), fentanyl ( 1 µg kg -1 hr -1 ) and midazolam (40 µg kg-1 hr hr 1] from a separate infusion pump. The doses were then decreased to reach 5 µg kg -1 min -1 , 0.5 µg kg -1 hr­ 1 and 10 µg kg -1 hr -1 for ketamine, fentanyl and midazolam respectively at time of closure. The lungs were ventilated using Oxygen enriched air (FiO2 = 0.35) with a tidal volume of 8 ml kg -1 using a pressure regulation volume controlled/support mode at a rate of 12-15/min. Surgery was performed while the patient in Trendlenberg position with approximately 40 o head-down tilt. All procedures were performed through 5-ports trans-peritoneal approach. The neo­bladder was tailored extra-corporeally through a small incision. The abdominal cavity was insufflated by CO 2 at 12 mmHg.

Crystalloid fluids were administered for replacement and maintenance guided with CVP. Blood transfusion was instituted when deemed necessary guided with losses and hematocrit. Peri­operative monitoring included 5 lead ECG, pulse oximeter, capnography, invasive arterial blood pressure and CVP. Recorded data included lung mechanics (dynamic compliance; Dyn C, peak airway pressure; Pp and mean airway pressure; Mp), peripheral oxygen saturation "SpO2", end-tidal CO 2 tension " EtCo 2 " and hemodynamic variables heart rate; HR, mean arterial blood pressure; MBP and CVP. These data were recorded after induction of general anesthesia (basal), after Trendlenberg position, 15, 30, 60 min after CO 2 insufflation, before deflation and 15, 30, 60 min after deflation.

Lung mechanics data were recorded from Servo screen 390 attached to Servo 300 ventilator. The duration of CO2 insufflation, amount of total blood loss, state of recovery and postoperative outcomes were also recorded. After conclusion of procedure, all patients were escorted to high dependency unit where ventilator support was continued for around 2 hr while patients in head up position.

Prophylaxis against thromboembolism was carried out with low-molecular weight heparin and elastic stockings.

Statistical analysis was carried out using SPSS program version 10.0, Chicago, IL, USA. Data were described in means and 95% confidence interval. Repeated measures analysis of variance was used to detect within group differences. Paired sample t-test was used to detect changes in each variable. A value of P < 0.05 was considered significant.


   Results Top


The demographic and clinical characteristics of the studied patients are shown in [Table 1]. Two patients were excluded from the study as they were converted to open surgery due to uncontrolled bleeding. Fourteen patients (48.2%) had preoperative medical diseases and 11 patients (38%) received blood (1 to 3 units). After Trendlenberg position, dynamic compliance decreased while peak airway pressure; Pp and mean airway pressure; Mp increased significantly in comparison to basal values. During insufflation a further significant change in the same direction was observed. After deflation, lung compliance, peak airway pressure and mean airway pressure remained significantly high in comparison to basal values [Table 2]. EtCO 2 showed progressive significant increase throughout the procedure to reach maximum value before deflation. However, except before deflation value, all the recorded readings of EtCO 2 were kept within accepted range. Heart rate decreased and the mean blood pressure increased significantly in comparison to the basal reading during nearly all insufflation period. CVP increased significantly throughout the study period [Table 3]. Three patients (10.3%) needed re-intubation and ventilation for extra 4 hr because of signs of airway obstruction. All patients developed conjunctival edema. Further complications were encountered in 8 patients (25.8%) in the form of subcutaneous emphysema in the chest extending up to the neck (6 patients), postoperative nausea and vomiting (1 patient) and second day pulmonary embolism (1 patient). With the exception of 5 patients (16.1%), all patients gradually ambulated from the second day.


   Discussion Top


This study revealed that laparoscopic radical cystectomy in the exaggerated Trendlenberg position is a challenging clinical setting to anesthetists due to the risks of position and long duration pneumoperitoneum. Effects of CO 2 insufflation and Trendlenberg position on pulmonary and hemodynamic variables were statistically significant but were tolerated by previously healthy patients of the study. The effects of pneumoperitoneum and Trendlenberg position on pulmonary functions in other laparoscopic surgeries have been extensively studied. These included decreased lung volumes and compliance [14] , with further demonstrable decrease after head down position but minimal effects on oxygenation and CO 2 elimination [12] . However, there was greater compromise of respiratory function in obese and elderly [15] .

In our study, about 50% reduction in compliance following CO2 insufflation was encountered compared with 30% in other laparoscopic surgery [14] [16]. It was reported that the decrease in compliance was immediately reversible upon abdominal deflation [17] but in our series the reduction in compliance as related to basal reading continued up to 1 hr after deflation. This may be explained by increased interstitial lung water resulting from exaggerated Trendlenberg position. This transudate increases lung rigidity and decreases compliance [18] . The significant increase in both peak and mean airway pressures after CO2 insufflation and head down position confirmed the decrease in compliance and not the increase in airway resistance indicated by high peak pressure only. The pulmonary effects may be responsible for subcutaneous emphysema encountered in 6 cases. One of the limitations in our study is that we did not measure intraocular (IOP) or intracranial (ICP) pressures. However, the presence of conjunctival edema in almost all patients indicates possible increase in IOP and ICP. Consequently, we deliberately kept the patient on ventilator support in head-up position during the early recovery period. Although less reliable as a predictor of PaCO2 during laparoscopy than conventional open surgery, EtCO2 is useful as a gross guide to the adequacy of ventilation [14] . We reported a progressive significant increase in EtCO2 reaching its maximum reading before deflation. However, all readings were within the accepted range recorded in previous literatures [4] . The mean arterial blood pressure and CVP increased significantly indicating increase in systemic vascular resistance and preload respectively [10],[11] . Nevertheless, these changes were well tolerated in both healthy and elderly patients with cardiovascular implications. The significant bradycardia was due to the effect of epidural anaesthesia in addition to balanced TIVA. Pneumoperitoneum and head-down position caused acute volume loading which antagonize the hypotensive effect of epidural anaesthesia, accordingly, the hemodynamic variables, except acute elevation of CVP, remained within accepted range all over the study period

One of the advantages of laparoscopic radical cystectomy is minimal blood loss with almost negligible transfusion rate as compared with open surgery. However, the average blood loss during laparoscopic radical cystectomy was 600 ml which is higher than reported during robotic laparoscopic radical cystectomy [19] and similar to open surgery [8] . In addition, more than one-third of our patients received blood transfusion. The contributing factors might be the early learning curve in this technique and possible vascular injury during lymphadenectomy (5 cases). Adverse events in the form of re-intubation in 3 patients because of signs of airway obstruction from edema of uvula which resolved with ventilation in head-up position. Hypoxemia in the first postoperative day was another adverse event with suspected pulmonary embolism (spiral CT). It was managed with heparinzation and non-invasive ventilation. Surgical emphysema likely from abdominal ports with normal chest-x ray was self-limited. Although laparoscopic radical cystectomy seems appealing for surgeons, the standard treatment is still open surgery [20] .

We concluded that laparoscopic radical cystectomy carries potential risks and should be reserved to physically fit patients.

 
   References Top

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10.Gannedahl P, Odeberg S, Brodin L, Sollevi A. Effects of posture and pneumoperitoneum during anaesthesia on the indices of left ventricular filling. Acta Anaesthesiol Scand 1996; 40: 160-66.  Back to cited text no. 10    
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13.Shorrab AA, Atallah MM . Total intravenous anaesthesia with ketamine-midazolam versus halothane - Nitrous Oxide - Oxygen anaesthesia for prolonged abdominal surgery. Eur J Anaesthesiol 2003; 20: 925-31.  Back to cited text no. 13  [PUBMED]  
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17.Fahy BG, Barnas GM, Nagle SE, Flowers JL, Njoku MJ, Agarwal M. Changes in lung and chest wall properties and abdominal insufflation of carbon dioxide are immediately reversible. Anesth Analg 1996; 82: 501-5.  Back to cited text no. 17  [PUBMED]  [FULLTEXT]
18.Lowe K, Alvarez D, King J, Stevens T. Phenotypic heterogeneity in lung capillary and extra_alveolar endothelial cells. Increased extra-alveolar endothelial permeability is sufficient to decrease compliance. J Surg Res 2007; 143: 70-77.  Back to cited text no. 18    
19.Menon M, Hemal AK, Tewari A, Shrivastava A, Shoma AM, El-tabey NA, Shaaban A, Abol-enein H and Ghoneim MA. Nerve-sparing robot-assisted radical cystoprostatectomy and urinary diversion. Brit J Urol Int 2003; 92: 232-36.  Back to cited text no. 19    
20.Huang GJ, Stein JP. Open radical cystectomy with lymphadenectomy remains the treatment of choice for invasive bladder cancer. Curr Opin Urol 2007; 17: 369­375.  Back to cited text no. 20  [PUBMED]  [FULLTEXT]



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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