Probability of live birth after IVF/ICSI treatments in female early onset cancer survivors: a Finnish population-based registry study.

STUDY QUESTION: Does the probability of a live birth after fresh IVF/ICSI cycles with autologous oocytes differ in early onset female cancer survivors compared to their siblings? SUMMARY ANSWER: The probability of a live birth was similar in female cancer survivors and siblings after four fresh IVF/ICSI cycles. WHAT IS KNOWN ALREADY: Fertility preservation strategies are rapidly being developed to help female cancer patients who wish to have children later. However, there are only a few studies available on fertility treatments and following live births in female cancer survivors before fertility preservation strategies became available. In one of them, the probability of a live birth was reduced after assisted reproductive technology with autologous oocytes in cancer survivors compared to siblings. STUDY DESIGN, SIZE, DURATION: In this retrospective, register-based study, data from Finnish registers on cancer, birth and prescribed medications were merged to identify 8944 female cancer survivors (diagnosed with cancer between 1953 and 2012 at the age of 0-40 years) and 9848 female siblings of survivors eligible for IVF/ICSI treatments between January 1993 and December 2012. PARTICIPANTS/MATERIALS, SETTING, METHODS: Fresh IVF/ICSI cycles and following live birth rates (LBRs) within 22-48 weeks in cancer survivors and siblings at the age of 20-41 years were identified. A binomial regression model with log-link function was used to calculate risk ratio (RR) for live births after fresh IVF/ICSI cycles in survivors compared to siblings, adjusting for attained age and calendar time. A Poisson regression model was used to estimate incidence rate ratios (IRRs) for an IVF/ICSI treatment, as well as overall live births, including both pregnancies after fertility treatments and spontaneous pregnancies, in survivors compared to siblings. MAIN RESULTS AND THE ROLE OF CHANCE: We observed an overall decreased LBR, irrespective of IVF/ICSI treatments, in cancer survivors compared to siblings (IRR 0.68, 95% CI 0.64-0.71). All in all, 179 (2.0%) survivors and 230 (2.3%) siblings were prescribed fertility drugs for IVF/ICSI treatments (IRR 0.72, 95% CI 0.62-0.84). For the first fresh IVF/ICSI cycle, the LBR was 17.2% among survivors and 15.7% among siblings (RR 1.13, 95% CI 0.72-1.87). The mean LBR after four fresh IVF/ICSI cycles was not statistically different in survivors compared to siblings. LIMITATIONS, REASONS FOR CAUTION: In this study, only IVF/ICSI treatments with autologous oocytes were included. The probability of a live birth after a frozen embryo transfer or oocyte donation could not be evaluated in this study. Information on miscarriages, extrauterine pregnancies or termination of pregnancies was not available. WIDER IMPLICATIONS OF THE FINDINGS: For those early onset cancer survivors, who received IVF/ICSI treatments, the probability of live birth was not different from siblings who received IVF/ICSI treatments. However, an overall decreased LBR, irrespective of IVF/ICSI treatments, was observed in cancer survivors compared to siblings, indicating that cancer survivors receiving IVF/ICSI treatments in our study consisted of a selected group with at least a moderate ovarian reserve. STUDY FUNDING/COMPETING INTEREST(S): This study was supported by a grant from the Cancer Foundation (Finland) (grant number 130079) and by a grant from LähiTapiola. The authors have no potential conflicts of interest. TRIAL REGISTRATION NUMBER: N/A.

Fatal inhalation injury caused by airway fire during tracheostomy.

A 45-year-old man needed emergency tracheostomy and cranioplasty. He was intubated with a cuffed oral polyvinylchloride endotracheal tube and ventilated with 100% oxygen before tracheal incision. During opening of the trachea using diathermy, a popping sound was heard and flames originating from the tracheal incision were observed. The endotracheal tube was charred and its lumen had melted. Immediately after the incident, bronchofibroscopic examination revealed inhalation injury. After remaining for 8 weeks in hospital, the patient was transferred to a health care centre, where he was found dead in his bed.

Supplemental 80% oxygen does not attenuate post-operative nausea and vomiting after breast surgery.

BACKGROUND: Although supplemental oxygen has been shown to be as effective as ondansetron in the prevention of post-operative nausea and vomiting (PONV) in one study in abdominal surgery patients, the antiemetic efficacy of supplemental oxygen is controversial on the basis of studies with other patients. We compared the efficacy of 80% and 30% oxygen in decreasing PONV in breast surgery. Ondansetron was used as an active control. METHODS: Ninety patients were given a standardized sevoflurane anesthetic. They were randomly assigned to three groups: 30% oxygen in nitrogen and saline 2 ml intravenously (i.v.) at the end of surgery (group 30); 80% oxygen in nitrogen and saline 2 ml (group 80); and 30% oxygen in nitrogen and ondansetron 4 mg (group O). Oxygen was administered during surgery and up to 2 h after surgery. RESULTS: The incidence of total response (no retching or vomiting, no nausea) during the first 24 post-operative hours was not different between group 80 (17%) and group 30 (11%) but was higher in group O (43%) than in group 30 (P<0.05). Compared with group O, patients in group 80 experienced more vomiting during the study period 0-24 h (66% vs. 32%; P<0.05) and more nausea during the period 6-24 h (72% vs. 39%; P<0.05). There was no difference between the groups in their risk for PONV, pain scores, opioid consumption, or patient satisfaction. CONCLUSIONS: In this study, supplemental 80% oxygen administration failed to decrease PONV in breast surgery.

Thyroid storm prior to induction of anaesthesia.

A 53- year-old woman without a previous history of thyroid disease was scheduled for mastectomy. On arrival in the operating theatre unpremedicated she appeared restless and tachycardic. Midazolam and fentanyl was administered intravenously. Concomitantly, sinus tachycardia developed and a flush reaction was observed in the skin of the thoracic region and neck. The blood pressure increased to 265/160 mmHg and the patient lost consciousness and became apnoeic. Unconsciousness and apnoea lasted for approximately 25 min and the operation was postponed. Further investigations revealed an elevated serum free thyroxine level and suppressed serum thyrotropin diagnostic of hyperthyroidism. The serum TSH receptor antibody concentration was elevated, indicating that the patient was suffering from Graves' disease. We present a case of a previously unknown hyperthyroid patient, with breast cancer, presenting as a thyroid crisis on induction of anaesthesia. Although being quite a rare occurrence, unsuspected thyroid disease should be borne in mind when an agitated patient enters the operating theatre.

Acceptability and patterns of endometrial bleeding in estradiol-based HRT regimens: a comparative study of cyclical sequential combinations of trimegestone or norethisterone acetate.

OBJECTIVE: This randomized, double-blind, multicenter study was planned to compare the efficacy and tolerance of a novel oral regimen containing estradiol (2.0 mg) sequentially combined with trimegestone, at a daily dose of either 0.25 mg or 0.5 mg, with a standard hormone replacement therapy containing estradiol and norethisterone acetate (E2 + NETA) in the treatment of climacteric symptoms. METHODS: The study was conducted over 13 cycles, each of 28 days, and involved 487 subjects, of whom 349 completed the study. RESULTS: All three treatments were equally effective in alleviating hot flushes and showed a progressive and significant reduction in the value of the Kupperman index. The treatments diminished equally effectively urogenital signs and symptoms. All treatments were well tolerated and the incidences of adverse events associated with each treatment were similar across the treatment groups. The duration of expected withdrawal bleeding was shorter in the estradiol + trimegestone 0.5 mg group than in the estradiol + trimegestone 0.25 mg or E2 + NETA group. CONCLUSION: All treatments were effective and well tolerated, providing significant relief from climacteric symptoms. Treatment with estradiol + trimegestone 0.5 mg provided the most favorable bleeding pattern.

The adverse hemodynamic effects of anesthesia, head-up tilt, and carbon dioxide pneumoperitoneum during laparoscopic cholecystectomy.

BACKGROUND: The increased intra-abdominal pressure during pneumoperitoneum, together with the head-up tilt used in upper abdominal laparoscopies, would be expected to decrease venous return to the heart. The goal of our study was to determine whether laparoscopy impairs cardiac performance when preventive measures to improve venous return are taken, and to analyze the effects of positioning, anesthesia, and increased intra-abdominal pressure. METHODS: Using invasive monitoring, hemodynamic changes were investigated in 15 ASA class I or II patients under isoflurane-fentanyl anesthesia during laparoscopic cholecystectomy. Before laparoscopy, the patients received an intravenous (IV) infusion of colloid solution if cardiac filling pressures were low, and their legs were wrapped from toes to groin with elastic bandages. Measurements were taken while the patients were awake in the supine (baseline) and head-up tilt (15-20 degrees) positions, and after the induction of anesthesia in the same positions. Measurements were repeated at regular intervals during laparoscopy (intra-abdominal pressure at 13-16 mm Hg), after deflation of the gas, and in the recovery room. RESULTS: With the passive head-up tilt in awake and anesthetized patients, the cardiac index (CI), stroke index (SI), central venous pressure (CVP), and pulmonary capillary wedge pressure (PCWP) decreased, and systemic vascular resistance increased. With the patient under anesthesia, SI decreased, but CI did not change significantly as a result of the compensatory increase in heart rate. Carbon dioxide (CO2) insufflation at the start of laparoscopy produced increases in CVP and PCWP as well as mean systemic and mean pulmonary arterial pressures without changes in CI or SI. Toward the end of the laparoscopy, CI decreased by 15%. The hemodynamic values returned to nearly prelaparoscopic levels after deflation of the gas, and CI was elevated during the recovery period, whereas systemic vascular resistance was decreased in comparison with the baseline. CONCLUSIONS: By correcting relative dehydration and preventing the pooling of blood, CI decreased less than 20% during pneumoperitoneum as compared with the baseline awake level. The head-up positioning accounts for many of the adverse effects in hemodynamics during laparoscopic cholecystectomy.

Effect of an estradiol gel with monthly or quarterly progestogen on menopausal symptoms and bleeding.

OBJECTIVE: To assess the acceptability, efficacy and endometrial safety of transdermal estradiol gel (Divigel/Sandrena) combined with monthly or quarterly oral progestogen (medroxyprogesterone acetate). METHODS: This 12-month, multicenter, open-label study was carried out at 12 study centers in Finland and Sweden. A total of 395 postmenopausal women received 1 mg estradiol in 1 g gel, daily, with oral medroxyprogesterone acetate 10 mg for the first 12 days every month (groups I and III) or every 3 months (group II). The main outcome measures were relief of climacteric symptoms, bleeding patterns and endometrial safety. RESULTS: All regimens reduced the severity of hot flushes, sweating episodes and vaginal dryness. In groups I and III, approximately 80% and 70% of women, respectively, had regular monthly withdrawal bleeding (excepting the first cycle), with irregular bleeding in 8.3% and 5.3% of treatment months. In group II, approximately 94% of women had regular tri-monthly withdrawal bleeding, with irregular bleeding in 10.7% of the treatment months. Endometrial hyperplasia was observed in 0.3% of women. More than 87% of subjects completed the study, and 97% of these rated the gel as acceptable or convenient. CONCLUSIONS: Both the 1- and 3-month regimens were equally effective in controlling climacteric symptoms and protecting against endometrial hyperstimulation. The bleeding patterns were comparable between groups and were similar to those reported for oral estrogens. Estradiol gel was highly acceptable to the majority of women.

Effects on the hemostatic system and liver function in relation to Implanon and Norplant. A prospective randomized clinical trial.

In this prospective randomized clinical trial, two long-term contraceptive implants were studied with respect to hemostasis and liver function in 86 healthy young women. The two implants used were Implanon, containing the progestagen etonogestrel (the biologically active metabolite of desogestrel) and Norplant, the implant containing the progestagen levonorgestrel. The results of the trial showed that both implants had similar small effects on the hemostatic system that are not suggestive of a tendency towards thrombosis. The effect on liver function was characterized by increases in total bilirubin and gamma-glutamyl transferase and decreases in alanine aminotransferase and aspartate aminotransferase.

Effects of different hormone replacement regimens on postmenopausal women with abnormal lipid levels. Menopause Study Group.

OBJECTIVES: A retrospective, subset analysis of the prospective Menopause Study Group data was performed to determine the effects of four conjugated estrogens (CE) + medroxyprogesterone acetate (MPA) regimens and one unopposed CE regimen on the lipid profiles of women with abnormal lipid levels (n = 525). Previously unpublished data on the entire study population were also reviewed to determine the effects of these hormone replacement regimens on blood pressure and weight (n = 1368, 1374, respectively). METHODS: During a 1-year, prospective trial, all patients took CE. Groups A and B also took continuous MPA 2.5 and 5 mg, respectively, C and D took MPA 5 and 10 mg for the last 14 cycle days of each 28-day cycle, and E took matching placebo tablets to replace MPA. RESULTS: After 1 year, all five regimens were directly associated with significant elevations in high density lipoprotein-2 (HDL2) cholesterol and significant reductions in low density lipoprotein (LDL) cholesterol (p < 0.05), although unopposed estrogen produced the greatest increase in HDL2 cholesterol. The CE + MPA regimens were also associated with significant decreases in total cholesterol. Triglyceride levels did not change significantly from baseline in any treatment group (baseline values > 1.808 mmol/l (> 160 mg/dl)), although the CE + MPA regimens were associated with a mean triglyceride decrease and CE-only women (n = 8) had a mean triglyceride increase. No regimen produced significant weight or blood pressure changes. CONCLUSIONS: This analysis suggests that hormone replacement therapy (CE + MPA), used in appropriate dosages, may alter the HDL2 cholesterol and LDL cholesterol lipoproteins in postmenopausal women with borderline lipid levels (a higher-risk population) in a cardioprotective manner.

Transdermal oestradiol gel in the treatment of the climacterium: a comparison with oral therapy.

OBJECTIVE: To compare two doses of a transdermal oestradiol gel (Divigel/Sandrena) plus oral sequential medroxyprogesterone acetate (MPA) with oral oestradiol valerate plus oral sequential MPA (Divina/Dilena). DESIGN: Two year, randomised, open-label, comparative study. SETTING: Menopausal outpatient clinic in Helsinki. SUBJECTS: Postmenopausal women with climacteric complaints or already using HRT. INTERVENTIONS: (1) One gram gel containing 1 mg oestradiol for 3 months plus 20 mg oral MPA during the last 14 days; (2) 2 g gel containing 2 mg oestradiol for 21 days plus 10 mg oral MPA during the last 14 days; (3) 2 mg oestradiol valerate tablets for 3 weeks plus 10 mg oral MPA during the last 10 days. In all groups, each treatment period was followed by a 7-day medication-free interval. MAIN OUTCOME MEASURES: Climacteric complaints, bleeding control, bone mineral density, biomarkers of bone metabolism, lipid profile, tolerability and safety. RESULTS: With each preparation, climacteric complaints were significantly reduced and good bleeding control was obtained. In addition, maintenance of bone mineral density as well as a reduction of bone turnover was achieved in all groups. Lipid parameters showed no unfavourable changes. Continuation rates were similar in all groups with overall 74% of patients completing the first year, whereas 94% of patients who elected to continue completed the second year. Tolerability of the gel was good: only 1.7% of patients discontinued treatment due to skin irritation. CONCLUSIONS: Transdermal oestradiol gel and oral oestradiol valerate tablets, used in combination with oral sequential MPA, are effective regimens of HRT in postmenopausal women. Transdermal oestradiol gel is an efficient, well-tolerated form of HRT.

Effects of transdermal oestrogen therapy in postmenopausal women: a comparative study of an oestradiol gel and an oestradiol delivering patch.

OBJECTIVE: To compare the efficacy, safety and tolerability of an oestradiol gel (1.0 mg of oestradiol daily, Divigel/Sandrena) with those of an oestradiol delivering patch (delivering 50 micrograms oestradiol/24 h, Estraderm TTS) in hormone replacement therapy of postmenopausal women. Dydrogesterone tablets (Terolut), 10 mg daily for the first 12 days of every month, were used as the progestogen component of the therapy. MAIN OUTCOME MEASURES: The effect of treatment on clinical symptoms and on endometrium, total body bone mineral density and lipid metabolism as well as the tolerability of the treatments with special emphasis on skin irritation and compliance were evaluated. DESIGN: An open, randomised, controlled, parallel-group trial of 12 months' duration. SETTING: The Medical Clinic of Kalevankatu, Helsinki, Finland. PARTICIPANTS: One hundred twenty postmenopausal women were treated with transdermal oestradiol combined with dydrogesterone. In addition, 25 women without HRT served as a reference group for the bone mineral density measurements. RESULTS: Both treatment regimens were equally effective in alleviating climacteric symptoms, preserving bone mineral density and were equally safe. A trend towards heavier bleeding was detected in patients treated with the oestradiol delivering patch. A statistically nonsignificant decrease of total cholesterol and triglyceride concentrations but no change in high-density lipoprotein cholesterol concentration was observed in both groups. The acceptability of the treatment was higher in the gel group (96.4%) than in the patch group (90.7%). Only two (3.3%) women using the oestradiol gel complained of skin irritation whereas 28 patients (46.7%, P < 0.001) using the oestradiol delivering patch reported this adverse effect. CONCLUSIONS: Both the oestradiol gel and the oestradiol delivering patch are equally effective in hormone replacement therapy but the gel preparation is less irritative to the skin.

Sexuality of young women surviving leukaemia.

This study was designed to assess the sexuality of young women surviving acute leukaemia in childhood or early adolescence. Thirty of 31 survivors were compared with 50 healthy age matched controls. Three methods were used: a self report questionnaire, a face to face interview conducted by a psychiatrist, and a projective psychological test. The age at initiation of dating and sexual activity, the frequency of sexual intercourse, and opinions on sexual behaviour were similar in the two groups. With regard to inner sexuality, however, the survivors differed significantly from the healthy controls. Their images of sexuality were more restrictive, and their attitudes, especially those concerning sexual pleasure, were more negative than those of the controls. Sexual identity among the survivors was less often feminine and more often infantile as compared with the controls. The findings obtained with the three methods of assessment were concordant.

Hormonal responses and cardiac filling pressures in head-up or head-down position and pneumoperitoneum in patients undergoing operative laparoscopy.

In order to determine if there are differences in stress responses, as reflected in neuroendocrine activation, we have compared data from two groups of patients undergoing laparoscopic surgery either in the head-up position for cholecystectomy or in the head-down position for hysterectomy. Arterial blood samples were obtained for measurement of serum concentrations of cortisol, catecholamines, renin activity and atrial natriuretic peptide (measured as N-terminal peptide of proANP), and haemodynamic data (pulmonary capillary wedge pressure, PCWP) were collected at the following times: in awake patients, supine at rest (baseline); in awake patients in the position used during surgery; during laparoscopy; and 2 h after surgery. The same anaesthetic technique and normocapnic mechanical ventilation were used in both groups. There were no significant differences between groups in cortisol or adrenaline concentrations, or in renin activity. There was, however, a three-fold increase in cortisol towards the recovery period in both groups. Noradrenaline concentrations increased more in the head-up group suggesting increased sympathetic nervous activity. In awake patients, plasma NT-proANP concentrations were significantly higher in the head-down tilt compared with the head-up position, and NT-proANP correlated well with PCWP. During pneumoperitoneum, however, NT-proANP concentrations remained low in spite of increased PCWP suggesting that inflation of the abdomen interferes with venous return. In conclusion, abdominal surgical laparoscopy in both the head-up and head-down positions caused marked activation of neuroendocrine responses. The two surgical positions, however, differed in their effect on the circulation. In awake patients, head-down tilt was associated with increased concentrations of plasma NT-proANP, indicating increased venous return and atrial stretch.

A randomised study to compare the efficacy and safety of new 17 beta-oestradiol transdermal matrix patch with Estraderm TTS 50 in hysterectomised postmenopausal women. The Lyrelle Study Group.

This study was designed to compare the efficacy and safety of two sizes of Lyrelle, a new matrix design transdermal oestrogen patch, with Estraderm TTS 50, a reservoir system. Three hundred and ninety-four (394) hysterectomised postmenopausal women between 30 and 65 years of age participated in this open-label, randomised, multicentre clinical trial. The main efficacy criterion was the reduction in the mean number of hot flushes per day at six months. Secondary efficacy end points included other climacteric symptoms as well as various psychofunctional and genitourinary disorders. A significant decrease from baseline in the mean number of hot flushes/day was observed in all three groups from the end of cycle 1, reaching 90% at the end of cycle 7. there was no statistically significant difference between Lyrelle 50 and Estraderm at any time point for any parameter; however, between-group differences between Lyrelle 80 and Estraderm for various parameters were seen in the first three cycles in favour of Lyrelle 80. A similar impact on blood lipid levels was observed in all three groups, without significant between-group differences. We conclude that the new Lyrelle patch is a highly effective system for transdermal oestrogen replacement therapy that may enhance long-term patient compliance.

Impaired body image of young female survivors of childhood leukemia.

The purpose of this study was to assess the body image of young female survivors of leukemia. Young female survivors of leukemia (n = 42) were compared with healthy age-matched control subjects (n = 69). The study included a semistructured face-to-face interview and a psychological test. The data were separated into three distinct evaluations of each subject's body image: 1) the subject's self-assessment, 2) evaluation by a psychiatrist, and 3) the Rorschach test. The body images of the survivors were inferior to those of the control subjects in all three evaluations (P < 0.001). The preceding leukemia was assessed still as extremely threatening in 26% of the survivors.

A randomized, double-blind, multicentre study comparing the clinical effects of two sequential estradiol-progestin combinations containing either desogestrel or norethisterone acetate in climacteric women with estrogen deficiency symptoms.

OBJECTIVES: The aim of this study was to compare a new estradiol-desogestrel (E2-DG) regimen with an E2-norethisterone acetate (NETA) combination (Trisekvens) regarding the treatment of menopausal complaints, bleeding pattern, histology of the endometrium and the occurrence of adverse experiences. METHODS: A total of 310 peri-/postmenopausal women with climacteric symptoms were randomly allocated to oral sequential treatment with either the E2-DG combination (1.5 mg E2 for 24 days with 0.15 mg DG for the last 12 days followed by 1 placebo tablet for 4 days) or with the E2-NETA combination (Trisekvens, 2 mg E2 for 22 days with 1 mg NETA for the last 10 days followed by 1 mg E2 for 6 days). Treatments were administered double-blind for 12 cycles of 28 days. RESULTS: One hundred and four women, 48 in the E2-DG group and 56 in the E2-NETA group, discontinued the study due to bleeding irregularities and various adverse effects. Both treatments reduced menopausal symptoms and complaints effectively and almost equally. The alleviation of perspirations and the improvement of general fitness were more apparent (P = 0.009) during cycle 1 with the E2-NETA treatment but were greater (P < 0.02) during the last 9/10-12 cycles of E2-DG treatment compared to E2-NETA. Regular withdrawal bleeding appeared in 93% and 90% of the women during treatment with E2-DG and E2-NETA, respectively. Intermenstrual bleeding occurred in 8% of women receiving E2-DG and in 13% of women treated with E2-NETA. The corresponding figures for intermenstrual bleeding-spotting were 21% and 22%. Secretory endometrium was detected in 65% and 54% of the samples taken at the end of treatment with E2-DG and E2-NETA, respectively. No hyperplasia or atypia was found. No serious adverse events related to treatment occurred. CONCLUSIONS: Both regimens alleviated effectively menopausal complaints and did not induce hyperplasia of endometrium. The minor differences recorded between the two regimens were probably due to the differences in their composition concerning the amount of estradiol and its distribution along the cycle, the amount and type of progestin and the length of estradiol/progestin combination phase.

Progestins.

The history of progesterone and hormone replacement therapy goes back to 1934 when Butenandt obtained crystalline progesterone and Kaufmann started to treat ovariectomized women with both estrogens and progesterone (Table 1). Today synthetic perorally active 19-nortestosterone and 17-alpha-hydroxyprogesterone derivatives are used in addition to contraception and hormone replacement therapy in a variety of gynecological disorders. In hormone replacement therapy progestin is added only to prevent development of hyperplasia of the endometrium and its consequences. However, because progestins may cause both subjective and metabolic adverse effects minimum effective antiproliferative doses are recommended. The duration of the progestin phase cannot be shortened to less than 10 days whereas the frequency of administration apparently can be reduced without increased risk of hyperplasia. Development of new modes of administration may further help in reduction of the doses.

Hemodynamic changes due to Trendelenburg positioning and pneumoperitoneum during laparoscopic hysterectomy.

More prolonged gynecological laparoscopic operations are being performed in recent years, and a steeper head-down position is required. The early reports of hemodynamic changes during gynecologic laparoscopy are conflicting, and the effects of anesthesia, head-down tilt and pneumoperitoneum have not been clearly separated. Invasive hemodynamic monitoring was carried out in 20 female ASA Class I-II patients who underwent laparoscopic hysterectomy. Baseline measurements were made in the supine, supine-lithotomy and Trendelenburg (25-30 degrees) positions in awake patients. Measurements were repeated in the supine-lithotomy and Trendelenburg positions after induction of anesthesia, during laparoscopy 5 minutes after the beginning of peritoneal CO2-insufflation (intra-abdominal pressure 13-16 mmHg) and at 15-minute intervals thereafter, after laparoscopy in the Trendelenburg and supine positions, after extubation and in the recovery room at 30-minute intervals. Patients received balanced general anesthesia with isoflurane in 35% O2 in an oxygen/air mixture. End tidal PCO2 was maintained between 4.5-4.8 kPa (33-36 mmHg) by changing the minute volume of controlled ventilation. The Trendelenburg position in awake and anesthetized patients increased pulmonary arterial pressures (PAP), central venous pressure (CVP) and pulmonary capillary wedge pressure (PCWP). These pressures increased further at the start of CO2-insufflation, decreased towards the end of the laparoscopy and reached pre-insufflation levels after deflation of pneumoperitoneum. The mean arterial pressure (MAP) increased at the beginning of laparoscopy in comparison with the pre-laparoscopic values. Heart rate (HR) was quite stable during laparoscopy. The cardiac index (CI) decreased with anesthesia from 3.8 to 3.2 1.min-1.m-2 and further during laparoscopy to 2.7 1.min-1.m-2, returning to pre-insufflation values soon after deflation. The stroke index (SI) changed in concert with the CI changes. The right ventricular stroke work index decreased during laparoscopy more than the left ventricular stroke work index. The right atrial pressure (CVP) exceeded the PCWP more often during laparoscopy than during any other phase of the procedure. Anesthesia and the Trendelenburg position increased the CVP, PCWP and pulmonary arterial pressures and decreased cardiac output. Pneumoperitoneum increased these pressures further mostly in the beginning of the laparoscopy, and cardiac output decreased towards the end of the laparoscopy. The risk of systemic CO2-embolus was increased during laparoscopy.

Ventilatory effects, blood gas changes, and oxygen consumption during laparoscopic hysterectomy.

We evaluated the ventilatory effects and blood gas changes of prolonged CO2-pneumoperitoneum in nor-moventilated patients and examined the respiratory and gas exchange consequences of head-down positioning (25-30 degrees) and CO2 insufflation into the peritoneal cavity in 20 patients without major cardiorespiratory disorders in various phases of laparoscopic hysterectomy. The patients received general anesthesia with isoflurane, fentanyl, and vecuronium, and minute ventilation (MV) was adjusted to maintain the PETCO2 at 33-36 mm Hg throughout the entire procedure, either by increasing the tidal volume (TV) and keeping the respiratory rate (RR) at 12/min (10 patients) or by changing the RR and maintaining the TV at 8 mL/kg (10 patients). Arterial and mixed venous blood samples were collected simultaneously for blood gas analysis and for measurements of oxygen consumption, and respiratory mechanics and gases were recorded by an anesthetic gas analyzer and side stream spirometry device. Oxygen consumption decreased with anesthesia, remained stable to the end of the laparoscopy, increased soon after deflation of the pneumoperitoneum, and reached preanesthetic values during recovery. The MV requirement increased by approximately 30% after the start of CO2 insufflation, then increased somewhat further toward the end of the laparoscopy, reaching the highest level a few minutes after deflation of the intraabdominal gas. The compliance decreased by 20% with the head-down position and by an additional 30% with the increased intraabdominal pressure. PaCO2 and mixed venous PCO2 increased with CO2 insufflation, and the arterial to end-tidal PCO2 (a-etPCO2) gradient increased by 1.5 mm Hg during laparoscopy. A mild metabolic acidosis developed.(ABSTRACT TRUNCATED AT 250 WORDS)