Combined effects of bilateral thoracic sympathectomy and hypercarbia on common carotid blood flow volume in dogs

BACKGROUND: The occurrence of acute hypercarbia during endoscopic thoracic sympathectomy is not rare when CO2 gas is used to collapse lung. Upper thoracic sympathectomy can increases cerebral blood flow (CBF) and hypercarbia also increases CBF. The purpose of this study was to analyze the changes in common carotid blood flow volume (CCBFV) before and after T2 thoracic sympathectomy at normocarbia and hypercarbia. METHODS: In nine anesthetized and mechanically ventilated dogs, we checked CCBFV using an ultrasonic flow probe under four experimental conditions: 1) before T2 sympathectomy at normocarbia, 2) before T2 sympathectomy at hypercarbia, 3) after T2 sympathectomy at normocarbia, and 4) after T2 sympathectomy at hypercarbia. We also measured heart rate, blood pressure and PaCO2 at each time. RESULTS: Hypercarbia increased CCBFV from 105.2 +/- 47.9 ml/min to 192.3 +/- 85.4 ml/min. In T2 sympathectomy/normocarbia state, CCBFV increased to 152.2 +/- 62.0 ml/min. In T2 sympathectomy/hypercarbia state, CCBFV increased to 230.2 +/- 100.1 ml/min. CCBFV in hypercarbia state, sympathectomy state and sympathectomy/hypercarbia state showed significant increases compared with those in baseline (P < 0.05). CCBFV in hypercarbia state and sympathectomy/hypercarbia state showed significant increases compared with those in sympathectomy state (P < 0.05). But CCBFV in hypercarbia state and sympathectomy/hypercarbia did not showed significant differences. CONCLUSIONS: This result suggests that hypercarbia increases CCBFV more than sympathetic denervation and thoracic sympathectomy under hypercarbia condition increases CCBFV more than sympathectomy only.

Anesthetic course and complications that were encountered during endoscopic thyroidectomy: A case report / 대한마취과학회지

Endoscopic thyroidectomy is gaining popularity, but it can increase the risk of certain complications. Carbon dioxide insufflation in the neck may cause adverse effects on hemodynamic and ventilatory aspects. We report the anesthetic course and complications that were encountered during endoscopic thyroidectomy. Although the surgery was successful, the patient developed signs of hypercarbia, subcutaneous emphysema and pneumothorax.

The use of chest band to prevent CO2 subcutaneous emphysema expansion: Two case reports / 대한마취과학회지

CO2 subcutaneous emphysema is one of the complications of laparoscopic surgery using CO2 gas. During laparoscopic surgery, CO2 gas can spread to the entire body surface through the subcutaneous tissue layer. Extensive CO2 subcutaneous emphysema results in hypercarbia and acute respiratory acidosis. Hypercarbia and acidosis can lead to decreased cardiac contractility and arrhythmia. A cloth band, 5 cm in width and 120 cm in length, was made with Velcro tape at both tips, and placed on the patient's xyphoid process level and inframammary fold to prevent CO2 subcutaneous emphysema. This report describes two successful cases using a chest band to prevent the expansion of CO2 subcutaneous emphysema.

Massive Subcutaneous Emphysema and Uncontrolled Hypercarbia during Laparoscopic Assisted Distal Gastrectomy: A case report / 대한마취과학회지

We experienced a case of massive subcutaneous emphysema and marked hypercarbia during a laparoscopic assisted distal gastrectomy. Forty minutes after the start of pneumoperitoneum, the end-tidal carbon dioxide (CO2) tension was raised rapidly up to 70 mmHg. At this time, subcutaneous emphysema was detected on the neck and anterior chest of the patient. Carbon dioxide insufflation was then stopped, and surgery was restarted when the end-tidal CO2 level was normalized. During a second laparoscopic trial, the patient developed hypercarbia unresponsive to marked hyperventilation. As the laparoscopic procedure terminated, the end-tidal CO2 level no longer increased. Subcutaneous emphysema remained even at the recovery room. The patient was transferred to a ward in the usual procedure, and was discharged uneventfully nine days thereafter.

Subcutaneous Emphysema, Hypercarbia and Increased Peak Inspiratory Airway Pressure during Endoscopic Thyroidectomy : A case report

Endoscopic thyroidectomy has been increasingly used because it is minimally invasive, provides better cosmetic results as well as less, post-operative pain. However, the technique is associated with complications that, include subcutaneous emphysema, hypercarbia and pneumothorax. We treated a 45 year-old female patient who had subcutaneous emphysema, hypercarbia and increased peak inspiratory airway pressure due to carbon dioxide administered during the endoscopic thyroidectomy. After the above problems occurred, we increased the minute ventilation with 100% O2. The operation was over after about one hundred twenty minutes and ventilation was adequate so that arterial blood gas findings returned to the normal range in the recovery room. The patient was treated conservatively with oxygen and recovered completely at the time of discharge from the Hospital

Anesthetic Management during Laparoscopic Excision of an Urachal Cyst in a Pediatric Patient: A case report / 대한마취과학회지

A 14-month-old female patient was admitted for the laparoscopic excision of a complicated urachal cyst. General anesthesia was induced with thiopental and rocuronium and maintained with sevoflurane and the intermittent administration of vecuronium. During the insufflation of CO2 her intra-abdominal pressure was maintained below 12 cmH2O to avoid excessive hypercarbia. Thirty minutes after CO2 insufflation initiation, end tidal CO2 increased to 74 mmHg at a peak inspiratory airway pressure of 24 cmH2O. Laparoscopic excision of the urachal cyst was performed within 2 hours without a further change in end tidal CO2, blood pressure, heart rate, or O2 saturation. Before extubation, O2 saturation by pulse oxymetry was 99% and end tidal CO2 was 45-50 mmHg. The patient was discharged without any problem 5 days after the operation. We report on this clinical experience and include a brief review of the literature.

Bronchospasm during the Maintenance of General Anesthesia: A case report / 대한마취과학회지

Although a bronchospastic attack is common during the induction and emergence of general anesthesia, it is quite rare during maintenance of it. We experienced a severe case of a bronchospasm in a male patient during the maintenance of general anesthesia. His past medical history indicated no risk factors for the bronchospasm except for heavy smoking. He suffered from poor ventilation, hypercarbia and a pneumothorax that occurred abruptly, 2 hours after inducing general anesthesia. Ten hours later, he recovered his normal respiratory function without any respiratory complication. This case highlights the possibility of a bronchospasm during the maintenance of general anesthesia.

Severe Hypercarbia after Prolonged Laparoscopic Surgery: A case report / 대한마취과학회지

Laparoscopic surgery is replacing conventional surgical techniques for many common operation. CO2 absorption is a problem associated with laparoscopic surgery. However, hypercarbia have been proved clinically safe with appropriate ventilatory changes. But most of the studies have been conducted during laparoscopic cholecystectomy, laparosopic gynecological surgery, and animal studies. Therefore, studies on the effects of prolonged pneumoperitoneun are lack. We experienced a case of severe hypercarbia after prolonged CO2 pneumoperitoneum. It is important that repeated arterial blood gas analysis during and especially after prolonged pneumoperitoneum to find hypercarbia.

Severe Hypercarbia after Prolonged Laparoscopic Surgery: A case report / 대한마취과학회지

Laparoscopic surgery is replacing conventional surgical techniques for many common operation. CO2 absorption is a problem associated with laparoscopic surgery. However, hypercarbia have been proved clinically safe with appropriate ventilatory changes. But most of the studies have been conducted during laparoscopic cholecystectomy, laparosopic gynecological surgery, and animal studies. Therefore, studies on the effects of prolonged pneumoperitoneun are lack. We experienced a case of severe hypercarbia after prolonged CO2 pneumoperitoneum. It is important that repeated arterial blood gas analysis during and especially after prolonged pneumoperitoneum to find hypercarbia.

Massive Subcutaneous Emphysema and Hypercarbia during Endoscopic Thyroidectomy: A case report / 대한마취과학회지

Endoscopic thyroidectomy is being performed increasingly, because it is less invasive and more cosmetically advantageous, and thus improves the postoperative quality of life. However, the technical aspects of this procedure can increase the risk of certain complications, which include subcutaneous emphysema, hypercarbia, pneumothorax, and pneumomediastinum. This report describes the case of a 37-year-old female patient who had subcutaneous emphysema and hypercarbia due to increased carbon dioxide absorption during endoscopic thyroidectomy. After increasing minute ventilation, paying cautious attention to signs of other complications, the operation proceeded and blood gas findings improved. The operation ended successfully and she showed no further problems.

Severe Hypercarbia by Subcutaneous Emphysema Occurring during Hand Assisted Laparoscopic Donor Nephrectomy: A case report / 대한마취과학회지

Hand assisted laparoscopic donor nephrectomy (HALDN) has recently emerged as a very attractive modality in standard donor nephrectomy because of its many advantages. However, it also has disadvantages, which include gas emboli, subcutaneous emphysema, hypercarbia, pneumothorax and pneumomediastinum. This case involves a male patient who had suffered from temporary hypercarbia due to increased carbon dioxide absorption due to massive subcutaneous emphysema about 1 hour after pneumoperitoneum during HALDN. Following multiple skin punctures with an 18 G disposable needle, chest compliance and blood gas findings improved. Three hours later the operation ended successfully and he was transferred to the recovery room, and show no further problems. We report upon this clinical experience and include a brief review of the literature.

Valuability of Propofol as Anesthetics and Effect of Hypercarbia on Awakening after Propofol TCI during Laparoscopic Cholecystectomy / 대한마취과학회지

BACKGROUND: It used to induce hypercarbia that carbon dioxide insufflated into the peritoneum in laparoscopic surgery. It might stimulate sympathetic nervous system, and decrease splanchnic circulation, hepatic function, and metabolism of anesthetics. The purpose of the present study was to examine the influence of hypercarbia on concentrations of propofol at the time of eye opening and recovery of orientation after propofol target controlled infusion (TCI) during a laparoscopic cholecystectomy. METHODS: Fifty patients were divided randomly into a laparoscopic group (group 1, n = 25) and an exploratory group (group 2, n = 25). A propofol infusion was started at a propofol target concentration of 6microgram/ml, and anesthesia was maintained at 4microgram/ml by using a Diprifusor (TM) turing the operation, intraabdominal pressure was maintained automatically at 12 14 mmHg by a CO2 insufflator and controlled ventilation settings were adjusted about 50 mmHg of PaCO2 after peritoneal insufflation. This ventilatory setting was not changed throughout the operation. We evaluated the estimated plasma concentrations of propofol at the time of eye opening and recovery of orientation in each group using user interface of a Diprifusor (TM). RESULTS: In the laparoscopic group, PaCO2, and PetCO2 increased significantly at 5, 15, 30 minutes after carbon dioxide insufflation, but there was no significant difference in concentrations of propofol at eye opening and orientation after propofol TCI between the two groups. CONCLUSIONS: Hypercarbia induced by insufflation of carbon dioxide into peritoneum didn't give rise to an influence on awakening concentrations after propofol TCI during a laparoscopic cholecystectomy.

Cardiovascular and Respiratory Instability Induced by Excessive Packing during Lower Abdominal Surgery: A case report / 대한마취과학회지

Retractor and packing usually aid to expose the surgical field and fascilitate surgical procedures. but excessive packing can impede venous return and reduce cardiac output. We experienced severe hypotension and ventilatory difficulty associated with excessive packing and traction in a patient undergoing radical hysterectomy. After removing the packing and extracting the intestine exterior to abdominal cavity, patient's ventilatory condition improved immediately and cardiovascular stability was achieved.

Physiologic Changes during Laparoscopic Surgery for Upper Urinary Tract / 대한비뇨기과학회지

PURPOSE: Presently laparoscopic urologic surgical procedures are being performed with increasing frequency. Despite the evolution of laparoscopic technique and instruments, the large set of physiologic alteration associated with laparoscopy are poorly understood. We have recently performed prospective study to evaluate the physiologic effects of pneumoperitoneum created during laparoscopic surgery. MATERIALS AND METHODS: Seventeen consecutive patients with various upper urinary tract diseases underwent laparoscopic surgeries at our institution. They were checked pre and postoperatively for such parameters as blood pressure, heart rate, arterial blood gas analysis(ABGA), end tidal CO2(ETCO2), peak airway pressure, temperature. Every patient was classified as ASA class 1 or 2 preoperatively. All insufflrated pressure was adjusted not to go over 14mmHg. All patients were positioned laterally for easier access to retroperitoneum. We evaluated the differences of various physiologic indices with statistical means. RESULTS: After 2hr insufflation, a marked hypercarbia and acidemia was observed intraoperatively suggesting that capnography may be an inadequate guide in controlling ventilation during the state of CO2 pneumoperitoneum in the upper urinary tract laparoscopic surgery. Eight patients suffered perioperative hypothermia(below 35.5degrees C). In the four of eight patients prolonged stay in recovery room were necessary due to their hypothermia. CONCLUSIONS: Because the upper urinary tract laparoscopic surgery causes many physiologic changes, surgeons should be aware of its meanings and clinical implications prior to achieving technical skillfulness in laparoscopic surgery.

Hypercarbia Due to Mistaken Supply of Carbon Dioxide Originating from Nitrous Oxide Gas Tank: A case report / 대한마취과학회지

A 49 year-old male was scheduled for a cholecystectomy, thereafter a 37 year-old female scheduled for removal of a epidural hematoma in the same operating room. Both of them had no specific medical problems and past medical histories for anesthesia. For those reasons, anesthesia was induced with thiopental sodium and succinylcholine with endotracheal intubation. After induction, vital signs including body temperatures were stable. But moisture dew in the unidirectional valves and corrugated tubes, and color changes of soda lime were discovered. At that time, severe hypercarbia was recognized by arterial blood gas analysis in both cases. In both cases, there were no malfunctions in unidirectional valves, expiratory valves, corrugation tubes, soda lime, ventilators and there connection parts in the anesthetic machines. Also there were no abnormalities of blood pressures, electrocardiograms, pulse oxymeters, temperatures and the pulse in the patient monitoring systems except capnography. At first, we thought that medical signs revealed malignant hyperthermias. But vital signs, air way pressures and functions of all kinds of anesthetic machine components including ventilators were normal. After discontinuing N2O gas deliveries in the operation room, hypercarbias disappeared. Thus, anesthetic gas delivery systems via central piping systems were checked and it was discovered that CO2 gas was in the N2O gas tank instead of N2O.

The Effects of Morphine on Hyperventilation Induced by Isocapnic Hypoxia / 대한마취과학회지

BACKGROUND: The purpose of this study was to define morphine's effects on resting ventilation and the ventilatory response to hypoxia and hypercarbia. METHODS: Six healthy nonsmoking young adult males were tested for the respiratory effects of intravenous morphine (0.15 mg/kg). Test began with baseline measurement of resting ventilation, isocapnic hypoxic ventilatory response (HVR), and normoxic hypercapnic ventilatory response (HCVR). After baseline measurement, morphine was administered and ventilatory responses were determined 20 and 40 min postinfusion. RESULTS: Morphine significantly decreased resting ventilation, hypoxic ventilatory response, and hypercarbic ventilatory response. Resting hypoventilation manifested as a peak rise in PETCO2 from 38.0+/-1.4 to 42.8+/-1.0 mmHg ( SEM) at 20 min (p<0.05). Hypoxic ventilatory response, measured as the slope of the ventilatory response to hypoxia, decreased from a control of 20.7+/-3.8 to 14.5+/-7.2 at 20 min after morphine (p<0.05). Hypercapnic ventilatory response, measured as the slope of the ventilatory response to hypercarbia, also decreased from 34.9+/-7.5 to 11.1+/-4.9 (p<0.05) 20 min after morphine. CONCLUSION: These decreased responsiveness to the chemical stimuli to breathing may contribute to the ventilatory depression frequently seen after administration of morphine.

Subcutaneous Emphysema and Pneumomediastinum during Laparoscopic Burch Operation / 대한마취과학회지

Laparoscopic Burch operation is one of laparoscopic surgery for stress urinary incontinence. Subcutaneous emphysema and hypercarbia are potential complications of laparoscopic surgery, but are more likely to occur in extraperitoneal surgery than in intraperitoneal surgery, since insufflated CO2 can diffuse easily into the surrounding tissues. We report a patient in whom pneumomediastinum and extensive subcutaneous emphysema developed during laparoscopic Burch operation. Transient hypoxemia was also accompanied with hypercarbia. Possible mechanisms are presented, along with discussion of prompt diagnosis and treatment. For the management of laparoscopic extraperitoneal surgery, it is necessary to be careful with monitoring of CO2 insufflation pressure, routine examination and palpation of chest wall, use of N2O with caution, increase of ventilation to eliminate CO2, and excluding other causes of subcutaneous emphysema and hypercarbia.

Changes of Arterial Carbon Dioxide Tension Do Not Affect Respiratory System Mechanics in Enflurane Anesthetized Cats / 대한마취과학회지

BACKGROUND: Bronchoconstriction is known to be induced by hypocarbia or hypercarbia. But the above effect has not been studied during general anesthesia. This study was proposed to investigate the effects of hypocarbia and hypercarbia on the respiratory system mechanics in 0.5 MAC enflurane anesthetized cats. METHODS: Six cats, weighing 3.0~3.6 kg were used. Pentobarbital sodium was intraperitonially injected to induce anesthesia and endotracheal intubation was followed. The anesthesia was maintained by 0.5 MAC enflurane, oxygen, and air (FiO2; 0.5). Intermittent mandatory ventilation was applied with Siemens Servo 900C ventilator. The inspiratory flow rate and tidal volume were fixed througout the experiment. Only the respiratory rate was adjusted to achieve normocarbia(PaCO2; 31~38 mmHg), hypercarbia(PaCO2; 38~45 mmHg) and hypocarbia(PaCO2; 24~31 mmHg), which were done not in the order. We used the flow-interruption technique to measure respiratory mechanics. The course of changes in the pressure along with the prefixed flow rate and volume were monitored and recorded with Bicore CP100 pulmonary monitor. The data were transfered to a PC and analyzed by Anadat processing software. Total respiratory system, airway and tissue viscoelastic resistances, and dynamic and static compliances were calculated for normocarbia, hypercarbia and hypocarbia. RESULTS: There are no significant differences of resistances and compliances of respiratory system among hypocarbia, normocarbia and hypercarbia. CONCLUSIONS: The changes in PaCO2 do not influence significantly the resistances and compliances measured by the flow interruption technique used in the study.

Effects of Augmented Minute Ventilation on Cardiovascular and Ventilatory Changes during the Laparoscopic Cholecystectomy under General Anesthesia / 대한마취과학회지

BACKGROUND: The pneumoperitoneum created by CO2 insufflation during laparoscopic cholecystectomy has several potential hemodynamic and respiratory consequences. The purpose of this study is to investigate the effects of augmented minute ventilation on cardiovascular and ventilatory changes and to prevent hypercarbia due to CO2 insufflation during laparoscopic cholecystectomy. METHODS: Thirty-six patients were divided into three groups according to the level of minute ventilation. The three groups were: control group C (minute ventilation 100 ml/kg, respiratory rate 12 per minute), group R (MV 150 ml/kg, RR is 18 per minute) and group V (MV 150 ml/kg, tidal volume is 1.5 times as much as group C). We repeatedly measured mean arterial pressure , pulse rate , arterial blood gas analysis and end tidal carbon dioxide and peak inspiratory airway pressure before CO2 insufflation, 15 and 30 minutes after CO2 insufflation and 15 minutes after CO2 deflation. RESULTS: During CO2 insufflation, MAP significantly increased but PR showed little changes in all three groups. PaCO2 and PetCO2 increased in group C, whereas in group R and V, they remained unchanged during CO2 insufflation. But the level of PaCO2 in group V decreased more than in the other two groups after CO2 deflation,. PIP in group V increased 3 times as much as the control value. CONCLUSIONS: These results suggest that augmented minute ventilation in group R and V, prevented hypercarbia during CO2 insufflation and increasing the tidal volume in controlled ventilation was more effective than increasing respiratory rate after CO2 deflation.

Subcutaneous Emphysema following Laparoscopic Cholecystectomy / 대한마취과학회지

Subcutaneous emphysema is one of the complications of the pneumoperitoneum necessary to perform laparoscopy. We experienced a case of extensive subcutaneous emphysema which was manifested by severe hypercarbia with respiratory acidosis and tachycardia during laparoscopic cholecystectomy in 65 years old female patient. Hypercarbia was reversed rapidly by hyperventilation and subcutaneous emphysema was resolved spontaneously on postoperative 3rd day almostly. The possible cause of subcutaneous emphysema in this case is dissection of the insufflated carbon dioxide from the peritoneal cavity via a trocar site to a tract along subcutaneous tissue planes. Immediate recognition, evaluation, and treatment is necessary since this can be a life threatening complication. And tension peu-mothorax should be ruled out. It is safe to monitor end tidal carbon dioxide tension or arterial carbon dioxide tension during the laparoscopic cholecystectomy.