EFFECT OF CAPNOPERITONEUM ON POSTOPERATIV E CARBON-DIOXIDE HOMEOSTASIS

After laparoscopic cholecystectomy, carbon dioxide (CO2) must be exhal ed after resorption from the abdominal cavity. There is controversy ab out the amount and relevance of postoperative CO2 resorption. Without continuous postoperative monitoring, after laparoscopic cholecystectom y a certain risk may consist in unnoticed hypercapnia due to CO2 resor ption. Studies exist on the course of end-expiratory CO2 (P(e)-CO2) al one over a longer postoperative period of time in extubated patients d uring spontaneous breathing. The goal of this prospective study was to investigate the amount of CO2 resorbed from the abdominal cavity in t he postoperative period by means of CO2 metabolism. Methods. After giv ing informed consent to the study, which was approved by the local eth ics committee, 20 patients underwent laparoscopic cholecystectomy. All patients received general endotracheal anaesthesia. After induction, total IV anaesthesia was maintained using fentanyl, propofol, and atra curium. Patients were ventilated with oxygen in air (FiO2 0.4). The in tra-abdominal pressure during the surgical procedure ranged from 12 to 14 mm Hg. Thirty minutes after releasing the capnoperitoneum (KP), CO 2 elimination (VCO2), oxygen uptake (VO2), and respiratory quotient (R Q) were measured every minute for 1 h by indirect calorimetry using th e metabolic monitor Deltatrac according to the principle of Canopy. As suming an unchanged metabolism, the CO2 resorption (DELTAVCO2) at any given time (t) can be calculated from DELTAVCO2 (t) = VCO2 (t) - RQ(pr eop) VO2 (t). It was thus necessary to define the patient's metabolism on the day of operation. The first data were collected before surgery and after introduction of the arterial and venous cannulae for a 15-m in period. Measuring point 0 was determined after exsufflation of the KP and emptying of the remaining CO2 via manual compression by the sur geon at the end of surgery. Patient's tracheas were extubated and meta bolic monitoring started 30 min after release of the KP for 60 min. Si multaneously, a nasal side-stream capnometry probe was placed and the PeCO2 and respiratory frequency (RF) were obtained by the Capnomac Ult ima (Datex) and registered every minute as well. Values were averaged over four periods of 15 min each. An arterial blood gas sample was dra wn at the end of every 15-min period. Postoperative pain was scored by a visual analog scale and completed by a subjective index questionnai re on general well-being. All data were analysed by the Friedman or Wi lcoxon test; P<0.05 was considered significant. Results. The findings do not indicate CO2 resorption in the postoperative period after lapar oscopic cholecystectomy (Tables 2 and 3, Fig. 1). Arterial CO2 as well as PeCO2 were elevated postoperatively (45 mm Hg vs. 36 mm Hg intraop eratively), while VCO2 and VO2 were unchanged when compared to the pre operative measuring period. The postoperative RF was comparable to pre operative values. Calculated DELTACO2 was lower than 10 ml/min and wit hin accuracy of measurements. The postoperative pain index ranged betw een 3 and 4, and 3.75-15 mg piritramid was administered. All patients felt tired immediately after the operation, but scores improved slight ly at the end of the 60-min period of metabolic monitoring. Conclusion s. There is no significant resorption of CO2 from the abdominal cavity later than 30 min after releasing the KP. Up to this time, any CO2 re maining in the abdominal cavity after careful emptying by the surgeon has been resorbed and exhaled. An increased PeCO2 as late as 30 to 90 min postoperatively should rather be considered a consequence of resid ual anaesthetics and narcotics than of CO2 resorption.