IMPACT OF POSITIONING AND CONSTANT CO2-PN EUMOPERITONEUM ON HEMODYNAMIC, RESPIRATORY AND ENDOCRINE PARAMETERS DURING LAPAROSCOPIC CHOLECYSTECTOMY (LCHE)

The effect of laparoscopic cholecystectomy on cardiopulmonary and endo crinological parameters results from various factors such as increased intraabdominal pressure (IAP), CO2, and the positioning. However, pos itioning has not yet been regarded. Reliable examination of the indivi dual influencing factors requires standardized anesthesiological proce dure and constant LAP. Presently, the effect of positioning is observe d separately from those effects caused by the pneumoperitoneum with CO 2 (PP) under standardized conditions. Methods: 40 patients with no his tory of cardiopulmonary disease were analyzed. Preoperative medication , induction and management of general anesthesia, positioning of the p atient and IAP (12 mmHg) were standardized. Hemodynamic, respiratory a nd endocrinological parameters were determined with the patient in a s upine position and in the position typical for the procedure (15 degre es head-down and 10 degrees slant to the left), each with and without PP. Heart rate (ECG), endexpiratory pCO(2) (peECO(2)), invasive blood pressure (radial art.), central venous pressure, partial arterial O-2 saturation (psaO(2)), and ventilation pressures (peak, plateau) were m onitored throughout anesthesia. The parameters pH, pCO(2), BE, HCO3-, COHb, vasopressine, lactate, and ammonia were analysed in arterial and venous blood samples at predetermined set points: base line, 10 min a fter CO2 insufflation, 10 min after desufflation, and 1 h after extuba tion (cf. table 1). Statistical analysis was performed using the Wilco xon-test with p less than or equal to 0.05 considered statistically si gnificant.Results: Insufflation of CO2 lead to a 12 % increase of hear t rate in supine position and to even 18 % in the position required fo r surgery Same significant changes were observed for arterial blood pr essure (21 or respectively 28 %). Central venous pressure increased by more than 200 %: after CO2 insufflation. Endexpiratory pCO(2) increas ed by 2.4 mmHg after CO2 insufflation in the supine position and by 5 mmHg in the surgical position. Ventilation pressures increased signifi cantly by 16 %. Analysis of the effect of PP on blood gases showed tha t pH decreased from 7.47 to 7.43, and arterial pCO(2) increased by 5.1 mmHg to 38.7 mmHg and increased further after desufflation to values of up to 43.9 mmHg. Arterial pO(2) decreased steadily (18 % after insu fflation). Vasopressine plasma levels increased exponentially from 3.0 3 to maximal values of 104.45 pg/ml. Ammonia and lactate showed the ex pected, nearly identical course. Lactate increased within the clinical ly and methodically irrelevative range, from 1.12 to 1.159 mmol/l. Amm onia decreased by 29 %. Conclusions: The observed changes, i.e. heart rate, central venous pressure, and arterial blood pressure are caused and altered by CO2 insufflation and the various positioning of patient s. The increased vasopressine concentration more than likely contribut es to these changes. The query whether the position of the patient als o causes a change in respiratory parameters and blood gas analysis can not be differentiated except for the endtidal pCO(2). Inspite of the o bserved changes no cardiopulmonary complications occurred in this pati ent group. Therefore, it seems possible to omit invasive monitoring in cardiopulmonary healthy patients. In patients with concomitant histor y of cardiopulmonary disease, however, deteriorations due to laparosco py should be thoroughly taken into consideration and studied further.