The duration of hemodynamic depression during laparoscopic cholecystectomy.

BACKGROUND: We previously evaluated the effects of pneumoperitoneum and patient position on hemodynamics during laparoscopic cholecystectomy and found that patient position had no effect on cardiac index (CI), stroke volume (SV), and left ventricular end diastolic volume (LVEDV). Analysis of that data showed that the hemodynamic depression associated with pneumoperitoneum was transient with values trending toward baseline during the operative period. The purpose of this study was to examine the duration of the adverse hemodynamic effects of pneumoperitoneum during laparoscopic cholecystectomy. METHODS: Thirty-eight patients undergoing laparoscopic cholecystectomy by a single surgeon were enrolled in the study. Hemodynamic data was collected via a transthoracic bioimpedance monitor. Baseline readings were taken prior to establishing pneumoperitoneum. Data was then collected continuously over the course of each case. Patients were compared to their baseline values. Data was analyzed every 5 min with the paired t-test used to determine statistical significance. RESULTS: All parameters were compared to baseline values. Baseline was defined as 5 min after the induction of anesthesia. With insufflation to 15 mmHg CO2, CI fell from a baseline value of 2.82 L/min/m2 to 2.66 L/min/m2 (p = 0.04), SV from 71.58 mL to 65.44 mL (p = 0.002), and LVEDV from 111.46 mL to 102.68 mL (p = 0.003). At 5 min, all values were further depressed. At 10 min all values were no longer significantly different from baseline. Values returned to baseline at 15 min and did not walver for the remainder of each case or the next 35 min. CONCLUSION: Patients undergoing laparoscopic cholecystectomy experience significant hemodynamic depression with pneumoperitoneum. These changes are short-lived and lose their statistical significance at 10 min from the time a patient undergoes pneumoperitoneum.

The effects of pneumoperitoneum and patient position on hemodynamics during laparoscopic cholecystectomy.

BACKGROUND: The purpose of this study was to prospectively examine the combined effects of pneumoperitoneum and the reverse Trendelenberg position on cardiac hemodynamics during laparoscopic cholecystectomy. METHODS: Thirty-nine patients undergoing laparoscopic cholecystectomy as performed by a single surgeon were enrolled in the study. Hemodynamic data were collected continuously using a transthoracic bioimpedance monitor. All patients were subjected to insufflation pressures of 15 mmHg. Data were examined using mixed analysis of variance (ANOVA). RESULTS: Cardiac index fell 11% with induction of anesthesia (p < 0.05), with stroke volume decreasing 7.2% (p < 0.05). Insufflation caused significant decreases in stroke volume (SV) left ventricular end diastolic volume (LVEDV) but not cardiac index (CI). Placing the patients in the reverse Trendelenberg position caused no significant changes in these parameters. There were no significant differences between ASA (American Society of Anesthesiologists) classes I and II patients when compared to ASA III patients. CONCLUSIONS: Patients undergoing laparoscopic cholecystectomy experience significant hemodynamic depression. The effect of general anesthesia is the most profound. Insufflation of the abdomen caused more mild hemodynamic effects in our study. The addition of a reverse Trendelenberg position did not alter the patient's hemodynamic status.

Emergency surgery in hematologic patients.

Patients at risk for clinically significant bleeding and who require urgent or emergent surgical procedures are encountered. Usually local causes are responsible, but a generalized hematologic defect may be uncovered. Quickly and effectively distinguishing the cause may be critical to rapid treatment and survival. A careful history, appropriate use of laboratory tests (e.g., partial thromboplastin time, prothrombin time, and platelet count), and knowledge of possible causes are key to prompt diagnosis and treatment. Bleeding from multiple sites, spontaneous bleeding, or unexpectedly severe bleeding suggests a systemic process. Immunocompromised or suppressed patients or systemically ill patients with chronic hepatic renal, lymphatic, and hematologic disorders are seen with urgent surgical problems. The key is rapid diagnosis and effective systemic and local therapy to counter the problem. The syndrome of diffuse "medical bleeding" frequently confronts the surgeon treating a patient who has received transfusions of more than 1.5 times blood volume. The coagulation defect is almost always associated with hypothermia and acidosis. Treatment consists in control of large-vessel bleeding by appropriate surgical techniques, blunt packing, and tamponade of diffuse bleeding, rapid rewarming of the patient, and adequate resuscitation for shock. Transfusion of platelets and fresh frozen plasma is empiric initially and subsequently guided by the clinical and laboratory coagulation profiles of the patient.

Intestinal perforation from gastrointestinal histoplasmosis in acquired immunodeficiency syndrome. Case report and review of the literature.

Gastrointestinal involvement with histoplasmosis in patients with the acquired immunodeficiency syndrome is a rare but documented phenomenon. Most patients present with diarrhea, fever, and abdominal pain. We present a case of a woman who tested positive for the human immunodeficiency virus antibody who developed an intestinal perforation due to Histoplasma capsulatum of the ileum. The patient, whose only risk factor was a blood transfusion 8 years earlier, had been previously diagnosed as having disseminated histoplasmosis with gastrointestinal involvement. While receiving oral antifungal treatment (itraconazole), she developed two separate areas of ileal perforation due to H capsulatum. Complications from gastrointestinal involvement with histoplasmosis, such as perforation, should be considered in patients infected with the human immunodeficiency virus with signs and symptoms suggesting abdominal disease.