Anesthetic Management during Laparoscopic Splenectomy in a Third Trimester Pregnant Patient with Idiopathic Thrombocytopenic Purpura / 대한마취과학회지

Anesthetic management during a laparoscopic splenectomy in a third trimester pregnant patient with idiopathic thrombocytopenic purpura (ITP) is critical because of the possibility of massive intra- and postoperative bleeding either maternal, fetal, or both. Laparoscopic surgery may be beneficial in pregnant patients compared to open laparotomy, but the safety of laparoscopic operations in pregnant women is under investigation. Pregnancy, especially in the third trimester, has been considered a contraindication of a laparoscopic procedure because the effect of CO2 pneumoperitoneum on the fetus and uterine blood flow is unclear. However, the benefits of laparoscopic surgery such as less stress response and a shorter hospital stay are postulated. The careful anesthetic management and close hemodynamic monitoring of patient and fetus will be helpful in making laparoscopic surgery safer in pregnant patients. We report on the anesthetic management during a laparoscopic splenectomy in a third trimester pregnant patient with ITP. We monitored the intestinal mucosal CO2 using Tonocap because we considered it could sensitively represent the uterine perfusion and intestinal CO2 status, and we also monitored the noninvasive cardiac output by using NICO . Although the arterial and intestinal mucosal CO2 tension, PrCO2 and CO2 gap increased gradually during the operation, hypercapnia was not remarkable. Tonocap represented the earliest changes which made us control intraabdominal gas inflation pressure by detecting fluctuations of CO2 gap and pHi even though other respiratory and monitored hemodynamic parameterswere quite stable during the procedure in this case. The patient was maintained well postoperatively and discharged with an improved condition. She had preterm labor at 36 weeks and 4 days of eventful gestation, but safely delivered a healthy baby by a normal spontaneous method.

A Comparison of Cardiac Output Measurements between Non-Invasive Partial Rebreathing Method and Invasive Intermittent Thermodilution Method during Coronary Artery Bypass Graft / 대한마취과학회지

BACKGROUND: A reliable non-invasive cardiac output measurement could enhance patient safety and reduce risk. Partial rebreathing cardiac output (RBCO) measurement is a non-invasive method based on a differential form of the CO2 Fick equation. The relative change in CO2 and ETCO2 in response to addition of dead space to the breathing circuit is used to measure cardiac output. The aim of this study was to compare this method in coronary artery bypass graft (CABG) patients during pre-cardiopulmonary bypass (CPB) and post-CPB with the currently accepted technique of intermittent thermodilution cardiac output (TDCO) measurement. METHODS: Eleven patients (n = 11, age = 50 +/- 13 years) undergoing CABG operations with CPB were studied. We measured the cardiac output non-invasively by using a RBCO monitor (NICO(R) , Novametrix Medical Systems Inc., USA) and used SpO2 and FiO2 to correct for intrapulmonary shunts. Invasively, using a pulmonary artery catheter (Hands-Off Thermodilution Catheter(R) , Arrow Co., USA) and 10 ml of iced 5% dextrose, an average of three consecutive TDCO was measured during end-expiration and compared with corresponding RBCO during pre-CPB and post-CPB for a total of 6 times respectively. Data was analyzed by paired T-test with significance set at P value < 0.05. RESULTS: Pre-CPB paired T-test analysis revealed no significant difference between partial rebreathing and bolus thermodilution cardiac output measurements. On the other hand, post-CPB differences between the two methods were significant (P < 0.05) and tended to decrease with time. Similarly, Pa-ETCO2 was increased abnormally after CPB, then decreased with time to a normal value. CONCLUSION: Post-CPB, partial rebreathing cardiac output did not correlate well with the thermodilution cardiac output. As a cause for the differences of the two cardiac output measurements, we couldconsider a thermal noise during thermodilution and an inadequate correction for the shunts in partial rebreathing measurements, but further investigation is needed.

Noninvasive Cardiovascular and Respiratory System Monitoring in Laparoscopic Cholesystectomy / 대한마취과학회지

BACKGROUND: The deleterious cardiopulmonary side effects immediately after positioning in reverse Trendelenburg and CO2 intra-abdominal insufflation during a laparoscopic cholecystectomy are well tolerated in healthy patients but can lead to serious morbidity and mortality in patients with a limited cardiopulmonary reserve. Using a continuous and non-invasive cardiac output monitor based on partial CO2 rebreathing method, we investigated the immediate cardiopulmonary changes caused by positioning in reverse Trendelenburg and CO2 intra-abdominal insufflation during a laparoscopic cholecystectomy, and assessed the applicability of the partial CO2 rebreathing method for the measurement of cardiac output in a laparoscopic cholecystectomy. METHODS: The investigation was carried out on 11 patients undergoing a laparoscopic cholesystectomy. The control values of cardiac index (CI), cardiac output (CO), mean arterial pressure (MAP), heart rate (HR), central venous pressure (CVP), systemic vascular resistance (SVR), dynamic compliance (Cdyn), airway resistance (Raw), peak inspiratory pressure (PIP) and end tidal CO2 partial pressure (PETCO2) were measured in the supine position after induction with target-controlled infusion of propofol (5 microgram/ ml). Five minutes after positioning in reverse Trendelenburg and CO2 insufflation, the same cardiopulmonay variables were measured and compared with the control values. RESULTS: CI, CO and CVP were reduced 33.3%, 31.9% and 29.0%, respectively (P < 0.05). MAP and SVR were increased 39.8% and 154.1%, respectively (P < 0.05). Cdyn was reduced 38.0% (P < 0.05). Raw and PIP were increased 22.8%, and 34.8%, respectively (P < 0.05), whereas HR and PETCO2 remained unchanged. CONCLUSIONS: The non-invasive cardiopulmonary monitor using partial CO2 rebreathing method, could be used with ease and safety in a laparoscopic cholecystectomy.

The Continuous Monitoring of Mixed Venous Oxygen Saturation for the Estimation of Cardiac Output Changes for Liver Transplantation in Dogs / 대한마취과학회지

BACKGROUND: In the management of liver transplantation, massive blood loss, interruption of venous retum to the heart, sudden infusion of acidic, cold and hyperkalemic blood from the graft, and uses of inotropic and vasoactive agents make cardiac output (CO) change unpredictably. We tried to find convenient method to estimate the change of CO by mixed venous oxygen saturation (SvO2) which can be monitored by pulmonary artery catheterization with fiberoptic oximeter using a spectrophotometer, By adapting the equation of oxygen transport and oxygen consumption(VO2), the equation CO=V/O2(Hbx0.134)x1/(SaO2-SvO2) can be obtained. If we assume the VO2 and hemoglobin concentration is constant and hypoxemia is excluded, CO might be proportional to I/(100-Sv O2). METHOD: For the management of orthotopic liver transplantations in 5 mongrel dogs, we continuously monitored Sv O2 with fiberoptic pulmonary catheter and intermittently measured the CO by thermodilution method according to operative phases. The Pearsons correlation coefficients between CO and mean arterial pressure, CO and S vO. and CO and 1/(100 SvO2) were measured in each dog. RESULT: The correlation coefficients between CO and 1/(100 SvO2) are raging from 0.74 to 0.98 with a corrected mean of 0.847 and significant in all dogs (p<0.05), and the correlation coefficients between CO and SvO2 are ranging from 0.67 to 0.96 with a corrected means of 0.786 and significant in 4 of 5 dogs. CONCLUSIONS: For the management of liver transplantation, the continuous monitoring of mixed venous oxygen saturation by a fiberoptic pulmonary catheter is helpful to detect changes of cardiac output.