Metabolic Effects of Carbon Dioxide Insufflation During Laparoscopic Surgery: Changes in pH, Arterial Partial Pressure of Carbon Dioxide (PaCO2) And End Tidal Carbon Dioxide (ETCO2)

Background: Laparoscopy involves inspecting the abdomen and pelvis using an endoscope. Carbon dioxide (CO2) is the gas that is commonly used to insufflate the abdomen so as to facilitate the surgical view. Aim: The present study was under taken to determine the Metabolic effects of carbon dioxide insufflation during laparoscopic surgery. Methods: An observational study on 50 patients above 18 years of age with physical status of American Society of Anaesthesiologists (ASA) Class I and II after obtaining approval from institutional ethical committee and consent of the patient was conducted in the Postgraduate Department of Anaesthesiology and Critical Care, Government Medical College Srinagar. Results: There was a progressive decrease in the pH during pneumoperitoneum in keeping with the hypercarbia. An increase towards baseline was observed during recovery but pH was still significantly lower than baseline 15 minutes into recovery (p<0.118). The Pco2 increased after 15 mins Co2 insufflation & peaked at 30 mins with mean & SD 42.82,2.775 & 46.16,2.909 respectively which was statically significant. Etco2 also increased after 15 mins of Co2 insufflation & peaked at 30 mins with mean 41.56 & 44.50 respectively which was statically significant. Similarly, Hco3 decreased over period of time with peak decrease at 30 mins of Co2 insufflation with mean 23.70, SD 1.919 & range 19-27. Conclusion: Co2 insufflation does bring metabolic changes in Ph, Pco2, Etco2 & HCO3 but with proper monitoring & management laparoscopic procedure can be safely performed.

Effect of CO2 Insufflation on Corrected QT Interval Prolongation during Laparoscopic Surgeries: A Prospective Observational Study

Introduction: Laparoscopic surgeries in various surgical specialties are most routinely performed with general anesthesia. Thephysiological effects of intra-abdominal CO2 insufflation combined with the variations in patient positioning can have a majorimpact on cardiorespiratory function. Prolongation of corrected QT interval (QTc) has been known to predispose torsades depointes, a potentially fatal ventricular arrhythmia may occur during CO2 insufflation. Our aim is to evaluate the effect of insufflationof CO2 on QT interval and QTc during prolonged laparoscopic surgeries.Methodology: Fifty patients of American Society of Anesthesiologists physical status 1 and 2, of either sex, between the agesof 25 and 65 years posted for laparoscopic surgeries included in the study. After general anesthesia, we measured mean arterialpressure, heart rate, SpO2 and ETCO2 before anesthesia induction, before CO2 insufflation, 30, 60, 120, and 150 min after CO2insufflation, 5 min after CO2 deflation, and at the end of surgery. We observed statistically significant increase of QTc intervalaround 120 min after CO2 insufflation.Conclusion: The cause of this QTc interval prolongation is multifactorial and clinical significance of producing life-threateningcardiac arrhythmias has to be determined.

Painless Colonoscopy: Available Techniques and Instruments

During colonoscopy, air insufflation to distend the lumen and facilitate careful inspection and scope insertion can induce pain and cause discomfort. Carbon dioxide (CO₂) insufflation can decrease abdominal pain and discomfort during and after colonoscopy. The advantage of CO₂ insufflation is the rapid absorption of the gas across the intestine. Another painless option is water-assisted colonoscopy. Two methods for water-assisted colonoscopy are available: water immersion and water exchange. In a recent direct comparison, the water exchange method was superior to water immersion, CO₂ insufflation, and air insufflation with respect to pain during colonoscopy, although it still had the disadvantage of being a time-consuming procedure. Cap-assisted colonoscopy is a simple technique involving the use of a small transparent cap attached to the tip of the scope. Three studies showed an advantage of this technique in terms of reduced patient discomfort compared with the conventional method. Three robotic colonoscopy systems (Endotics System [Era Endoscopy], NeoGuide [NeoGuide Systems Inc.], and Invendoscope [Invendo Medical]) have been introduced to evaluate pain reduction during colonoscopy, but none has been widely adopted and used in practice. In this review, clinical trials of several techniques and new devices for painless colonoscopy are described and summarized.

Experiencia preliminar con insuflacion de dióxido de carbono versus aire en colonoscopia ambulatoria con sedación sin monitoreo de anestesiología / Preliminary experience with carbon dioxide versus air insufflation in outpatient colonoscopies with sedation in absecence of anesthesiology monitoring

Introducción: El dióxido de carbono (CO2) es un gas rápidamente absorbido de la luz intestinal previniendo distensión abdominal, disminuyendo dolor intra y post procedimiento, requerimientos de sedación y duración del procedimiento. Objetivo: Comparar el efecto de la insuflación con CO2 y aire en el tiempo de intubación y extubación colónica, dosis de anestésicos y dolor abdominal en pacientes sedados sin monitoreo anestesiológico. Diseño: Estudio prospectivo, randomizado, hospital terciario (enero-mayo 2013). Pacientes y Métodos: 72 pacientes fueron sometidos a colonoscopia por un endoscopista experto. Pacientes con previa cirugía de colon, mala preparación, colonoscopias terapéuticas (resección y disección) fueron excluídos. 63 pacientes completaron el estudio, insuflación con aire (33) y CO2 (30). Videocolonoscopio Olympus 180 y Bomba CO2 UCR Olympus fueron usados. Tiempo intubación del ciego y extubación colon, dosis de anestésicos y dolor abdominal (post-procedimiento, 30 min y 24 horas) fueron evaluados. Resultados: De los pacientes insuflados con aire 7(21,2%) presentaron dolor inmediatamente post colonoscopia vs 2(6,7%) CO2 (p = 0,198), a los 30 minutos: 4 (12,1%) grupo aire vs 2 (6,7%) CO2 (p = 0,759) y a las 24 horas: 0 (0%) aire vs 2 (6,7%) CO2 (p = 0,431). Intubación cecal 4,5 ± 2,0 minutos grupo aire vs 3,9 ± 2,1 CO2 (p = 0,876) Extubación colon aire vs CO2 (3,9± 3,3 vs 5,7 ± 4,5 min) (p = 0,081). Del grupo aire 14 pacientes (42,2%) tenían cirugía abdominal previa vs 16 (53,3%) CO2 (p = 0,540). En el grupo CO2 se realizó terapéutica endoscópica 20 vs 11 pacientes grupo aire (p = 0,0771) Dosis Propofol 159 ± 40 mg aire vs 153 ± 63 mg CO2 (p = 0,642). Uso analgésicos post procedimiento 7 (21,21%) aire vs 4 (13,33%) CO2 (p = 0,624). Conclusiones: Nuestros resultados demuestran que pareciese ser que el CO2 no beneficia intubación y extubación del colon, reducción del dolor abdominal post procedimiento, dosis de propofol y uso de analgésicos en pacientes sedados sin monitoreo de anestesiología.

Introduction: Carbon dioxide (CO2) gas is rapidly absorbed from the intestinal lumen preventing bloating, reducing intra-and post-procedure pain, sedation requirements and duration of the procedure. Objective: To compare the effect of CO2 and air insufflation at the time of intubation and extubation colonic doses of anesthetic and abdominal pain in patients without monitoring anesthesiologist sedated. Design: Prospective, randomized, tertiary hospital (January- May 2013). Patients and Methods: 72 patients underwent colonoscopy by an experienced endoscopist. Patients with prior colon surgery, poor preparation, therapeutic colonoscopies (resection and dissection) were excluded. 63 patients completed the study, air insufflation (33) and CO2 (30). Videocolonoscopio Olympus 180 and Olympus UCR CO2 pump were used. Blind intubation time extubation colon, anesthetic doses and abdominal pain (post-procedure, 30 min and 24 hours) were evaluated. Results: Of the seven patients insufflated with air (21.2%) had pain immediately post colonoscopy vs 2 (6.7%) CO2 (p = 0.198), 30 minutes: 4 (12.1%) vs. air group 2 (6.7%) CO2 (p = 0.759) and 24 hours: 0 (0%) air vs 2 (6.7%) CO2 (p = 0.431). Cecal intubation group air 4.5 ± 2.0 minutes vs group CO2 3.9 ± 2.1 min(p = 0.876). Extubation colon group air vs group CO2 (3.9 ± 3.3 vs 5.7 ± 4.5 min) (p = 0.081). Group air 14 patients (42.2%) had previous abdominal surgery vs 16 (53.3%) CO2 (p = 0.540). In the CO2 group therapeutic endoscopy was performed 20 air group vs. 11 patients (p = 0.0771). Dose Propofol air 159 ± 40 mg vs. 153 ± 63 mg CO2 (p = 0.642). Use post-procedure pain 7 (21.21%) air vs. 4 (13.33%) CO2 (p = 0.624). Conclusions: Our results demonstrate that seemed to be that the CO2 does not benefi t bowel intubation and extubation, abdominal pain reduction post procedure, dose of propofol and analgesic use in monitoring sedated patients without anesthesia.

A Comparison of EtCO and PaCO in Laparoscopic Surgery during General Anaesthesia.

Introduction : Pneumoperitoneum leads to multiple changes in the mechanics of respiration and heart function.We decided to study the changes in arterial blood gas, EtCO and pH. We also studied hemodynamic changes due to pneumoperitoneum. Methodology : Fifty patients of ASA grade I and II, between the ages of20 to 65 years posted for elective laparoscopic surgery were selected. Arterial blood samples were collected pre-operatively.We also collected arterial blood intra-operatively at 10 min, 60 min and 120 min after insufflation of CO and soon after desufflation. Result : There was significant increase in EtCO after CO insufflation maximum at 60 minute and return to near baseline value after desufflation. There was significant rise in PaCO but within physiological range. There was significant decrease in pH maximum at the time of 120 minute. Blood pressure changes shows significant rise in diastolic blood pressure (p < 0.05). Conclusion : We concluded that diastolic blood pressure was kept under control by using volatile anesthetic agent. The EtCO PaCO and pH changes occurred significantly but remains within physiological range and corrected by increasing minute ventilation. Soon after desufflation all value returned to baseline in normal healthy patients. The EtCO correlate well with PaCO , so it is the best parameter to diagnose hypercarbia.

Distensión colónica con bomba de CO2: Impacto en el disconfort del paciente en los estudios de colonoscopía virtual / Colonic distention with CO2 insufflation: Impact on the patient's discomfort in virtual colonoscopy studies

Objetivos. Analizar el rol de la distensión colónica con CO2 y su influencia en el disconfort del paciente y en el tiempo de duración de la colonoscopía virtual en nuestra práctica diaria. Materiales y Métodos. Se estudiaron 200 pacientes, 50 insuflados con aire ambiental y 150 con CO2. Los estudios se realizaron con un equipo multidetector de 64 filas con cortes de 2 mm de espesor, 120 kV y 50 mAs. En todos los pacientes se efectuó una adquisición en decúbito supino y otra en prono. Se calculó el tiempo total del procedimiento en cada grupo y se utilizó una prueba "t de Student" para calcular las diferencias. Los pacientes completaron un cuestionario en referencia al grado de disconfort percibido. Se utilizó una escala de 0 a 3: 0- sin disconfort, 1- disconfort leve, 2- moderado y 3- severo. Se utilizó un test de proporciones para calcular las diferencias del grado de disconfort entre ambos grupos. Resultados. El tiempo total de los procedimientos fue de 30,5 minutos para los realizados con CO2 y 35,4 minutos para los efectuados con aire ambiental, con una diferencia de -4,9 min (p=0,0003). En la valoración del disconfort, en el grupo con insuflado con aire ambiental, el 44% de los pacientes manifestó un grado de disconfort moderado, mientras que en el grupo con CO2 el 76% manifestó ausencia de disconfort. Conclusiones. La colonoscopía virtual realizada con insuflación de CO2 permitió disminuir en forma parcial el tiempo total del examen y, de modo significativo, el disconfort durante y después del examen.

Objectives. To analyze the role of colonic distention with CO2 and its influence on patients' discomfort and the duration of the virtual colonoscopy procedure in our daily practice. Materials and Methods. Two hundred patients were evaluated, 50 were insufflated using room air and 150 with CO2. The studies were performed with a 64-row CT scanner using 2-mm slice thickness, 120 kV and 50 mAs. In all patients, scans were acquired both in prone and supine positions. We calculated the total procedure time in each group; a Student's t-test was used to calculate the differences. Patients completed a questionnaire about the degree of discomfort perceived. We used a scale of 0 to 3: 0- no discomfort, 1- mild, 2- moderate and 3- severe discomfort. We used a test of proportions to calculate the differences in the degree of discomfort between the two groups. Results. The total procedure time was 30.5 minutes for studies performed with CO2 and 35.4 minutes for those performed with room air, with a difference of -4.9 min (p =0.0003). As regards the assessment of discomfort, in the group insufflated with room air, 44% of patients reported a moderate degree of discomfort, while in the group insufflated with CO2, 76% of the patients expressed no discomfort. Conclusions. Virtual colonoscopy performed with CO2 insufflation partially reduced the total procedure time, and significantly reduced discomfort during and after the procedure.

The Effect of Lithotomy-Trendelenburg Position and Carbon Dioxide Insufflation on the Distance from the Upper Incisor to the Carina / 대한마취과학회지

BACKGROUND: The carbon dioxide (CO2) insufflation and lithotomy-Trendelenburg position are required in the laparoscopic gynecologic surgery. However, they can change the distance from the upper incisor to the carina. This may increase the risk of endobronchial intubation. METHODS: Nineteen patients, aged 29-50 yr, who were undergoing laparoscopic surgery were enrolled. We measured the distance from the upper incisor to the carina of them with fiberoptic bronchoscope. Measurements were taken in the each point of lithotomy position, lithotomy-Trendelenburg position, and lithotomy-Trendelenburg position after CO2 insufflation. RESULTS: The average distance from the upper incisor to the carina was 23.1 +/- 1.4 cm in the lithotomy position (0 degree) and was significantly decreased to 22.6 +/- 1.4 cm in the lithotomy-Trendelenburg position (15 degrees) (P<0.05). After CO2 insufflation into the abdominal cavity, the mean distance in the lithotomy-Trendelenburg position (15 degrees) was significantly decreased to 22.1 +/- 1.4 cm (P<0.05). CONCLUSIONS: The lithotomy-Trendelenburg position and CO2 insufflation decrease the distance from the upper incisor to the carina.

The Effect of CO2 Insufflation and Trendelenburg-lithotomy Position on Intraocular Pressure during Laparoscopy / 대한마취과학회지

BACKGROUND: The laparoscopy requires carbon dioxide (CO2) insufflation and Trendelenburg position for operational convenience. However, the above circumstances affect the cardiopulmonary systems significantly and intraocular pressure (IOP) may be also influenced. METHODS: In 27 non-glaucoma patients right and left intraocular pressure (RIOP, LIOP) were measured 5 minutes after induction of general anesthesia (control value), 15 and 30 minutes after CO2 insufflation and endelenburg-lithotomy position. RESULTS: The control values of RIOP and LIOP were 11.3 4.7 mmHg and 11.5 4.7 mmHg respectively. At 15 minutes after CO2 insufflation and Trendelenburg-lithotomy position, they increased to 16.6 5.3 mmHg and 17.0 5.9 mmHg (p<0.05). At 30 minutes, 18.4 3.5 mmHg and 18.2 4.1 mmHg (p<0.05). CONCLUSION: CO2 insufflation and Trendelenburg-lithotomy position increase IOP significantly in non-glaucoma patients during laparoscopy.

The Effects of Intraperitoneal Carbon Dioxide Insufflation and Head-down Tilt Position on Intracranial Pressure / 대한마취과학회지

BACKGROUND: The laparoscopy requires CO2 insufflation and posture changes for operational convenience. However, above circumstances affect the cardiopulmonary systems significantly. And then intracranial pressure (ICP) may be also influenced. METHODS: To ascertain the changes of ICP, an experimental study was performed, in which the parameters of hemodynamic status, arterial blood gas components and ICP were measured from twelve cases of Korean mongrel dogs. Pneumoperitoneum was produced by CO2 insufflation(15 mmHg) and then posture was altered from horizontal to head-down tilt of 20, 30 and 40 degree*. The measurements were obtained before (control), after CO2 insufflated horizontal position at 20, 40 and 60 minute in CO2 insufflated tilt** and CO2 deflated horizontal***. RESULTS: MAP and HR were not related to the insufflated time and degree of tilt. CVP and PCWP were significantly increased after CO2 insufflated tilt (p<0.01), but returned to control after deflated supine. PaCO2 was not significantly changed after CO2 insufflated supine, but grdually increased with degree of tilt and time (p<0.01). ICP was increased at 40 and 60 minute of 20degree, and at 20 minute of 30degree(p<0.05), then markedly increased at 40 and 60 minute of 30degree, and at 20, 40 and 60 minute of 40degreetilt (p<0.01). The increment of ICP was parallel with time and degree of tilt. But, ICP was returned to control after deflated supine. CONCLUSIONS: ICP was increased significantly during laparoscopy in head-down tilt, although it was reversible. Therefore, the patient must be given special attention during laparoscopy in whom the increment of ICP may be harmful.

The Effect of Cardiovascular and Arterial Blood Gas Changes during Laparoscope Assisted Vaginal Hysterectomy (LAVH) / 대한마취과학회지

In the last decade, advances in laparoscopic equipments have allowed the development of laparoscopic surgical treatment for gynecologic affeetion. The purpose of this study is to investigate the cardiovascular effects and blood gas changes during laparoscope assisted vaginal hysterectomy (LAVH) in Trendelenburg position and intraabdominal CO2 insufflation to obtain optimal surgical field. Mean arterial pressure (MAP), heart rate. SaO2, PaO2, end-tidal CO2 (ETCO2) PaCO2, pH, and peak airway pressure (PAP) were measured in twenty patients who underwent laparoscope assisted vaginal hysterectomy in Trendelenburg position and intraabdominal CO2 insufflation. Each measurement was taken immedistely after intubation (control), 15 minutes after Trendelenburg position, 30 minutes after CO2 insufflation, 15 minutes, 1 hour and 6 hrs. after CO2 deflation. ETCO2 and PAP were not measured 1 hour and 6 hrs. after deflation The results were as follows; 1) Mean arterial pressure and heart rate were decreased after Trendelenburg position, but increased after CO2 insufflation. 2) Arterial O2 saturation was decreased after CO2 insufflation, 1 hour after deflation 3) Arterial PO2 was decreased after CO2 insufflation. 4) End-tidal CO2 was increased after CO2 insufflation. 5) Arterial PCO2 was increased after CO2 insufflation compared to control value, but it was decreased at 15 minutes after CO2 deflation. Arterial PCO2 at 1 hour after CO2 deflation was higher than at 15 minutes after CO2 deflation and 6 hrs. after CO2 deflation. 6) Arterial pH was decreased after CO2 insufflation. 7) Peak airway pressure was increased after Trendelenburg position and after CO2 insufflation.

The Effect of Cardiovascular and Arterial Blood Gas Changes during Laparoscope Assisted Vaginal Hysterectomy (LAVH) / 대한마취과학회지

In the last decade, advances in laparoscopic equipments have allowed the development of laparoscopic surgical treatment for gynecologic affeetion. The purpose of this study is to investigate the cardiovascular effects and blood gas changes during laparoscope assisted vaginal hysterectomy (LAVH) in Trendelenburg position and intraabdominal CO2 insufflation to obtain optimal surgical field. Mean arterial pressure (MAP), heart rate. SaO2, PaO2, end-tidal CO2 (ETCO2) PaCO2, pH, and peak airway pressure (PAP) were measured in twenty patients who underwent laparoscope assisted vaginal hysterectomy in Trendelenburg position and intraabdominal CO2 insufflation. Each measurement was taken immedistely after intubation (control), 15 minutes after Trendelenburg position, 30 minutes after CO2 insufflation, 15 minutes, 1 hour and 6 hrs. after CO2 deflation. ETCO2 and PAP were not measured 1 hour and 6 hrs. after deflation The results were as follows; 1) Mean arterial pressure and heart rate were decreased after Trendelenburg position, but increased after CO2 insufflation. 2) Arterial O2 saturation was decreased after CO2 insufflation, 1 hour after deflation 3) Arterial PO2 was decreased after CO2 insufflation. 4) End-tidal CO2 was increased after CO2 insufflation. 5) Arterial PCO2 was increased after CO2 insufflation compared to control value, but it was decreased at 15 minutes after CO2 deflation. Arterial PCO2 at 1 hour after CO2 deflation was higher than at 15 minutes after CO2 deflation and 6 hrs. after CO2 deflation. 6) Arterial pH was decreased after CO2 insufflation. 7) Peak airway pressure was increased after Trendelenburg position and after CO2 insufflation.

Change of Hemodynamic Parameters and Plasma Catecholamine Level during Laparoscopic Cholecystectomy / 대한마취과학회지

In the last decade, advances in laparoscopic equipment have allowed the development of laparosopic surgical treatment for gynecologic affection. Intraabdominal endoscopy can be extended safely for cholecystectomy. Patients undergoing laparoscopy under general anesthesia exhibit various hemodynamic and blood gas change. To analyze the physiologic mechanisms of these hemodynamic effect of laparoscopic surgery during general anesthesia, the change of mean arterial blood pressure, heart rate, end tidal carbon dioxide and plasma catecholamine were studied. Ten patients undergoing cholecystectomy by means of laparoscopy were selected randomly. Measurements of the above parameters were made about 10 minutes after tracheal intubation when the conditon of the patients stabilized(control), shortly after completion of insufflation of peritoneal cavity with carbon dioxide, 30 minutes after insufflation of carbon dioxide and after deflation of carbon dioxide. There were significantly increased mean arterial pressure, end tidal carbon dioxide, plasma epinephrine, norepinephrine during CO2 insufflation into peritoneaf cavity and increased there after with deflation of CO from the peritoneal cavity in laparoscopic cholecystectomy. In conclusion, these hemodynamic parameter changes seem to be correlated to the increased catecholamine release which was caused by sympathetic stimulation during the laparoscopic cholecystectomy.