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Hemodynamic changes during laparoscopic cholecystectomy in patients with severe cardiac disease
H A Hein1, G P Joshi, M A Ramsay
1Department of Anesthesiology, Baylor University Medical Center at Dallas 75235-9068, USA.
Insights
Laparoscopic cholecystectomy causes significant hemodynamic changes in patients with severe cardiac dysfunction. Some patients required medication to maintain blood pressure and cardiac output, but no heart complications occurred.
Area of Science:
- Anesthesiology and Critical Care Medicine
- Cardiovascular Surgery
- Gastrointestinal Surgery
Background:
- Laparoscopic cholecystectomy is a common procedure, but its safety in patients with severe cardiac dysfunction is not well-established.
- Patients with severe cardiac dysfunction present unique challenges during surgery due to their limited physiological reserve.
Observation:
- This prospective study monitored hemodynamic parameters in 17 patients with severe cardiac dysfunction undergoing laparoscopic cholecystectomy.
- Invasive hemodynamic monitoring, including pulmonary artery cannulation, was employed.
- Key hemodynamic variables were recorded at multiple time points throughout the procedure.
Findings:
- Carbon dioxide insufflation led to significant decreases in cardiac index and significant increases in mean arterial pressure, systemic vascular resistance, and pulmonary artery occlusion pressure.
- Three patients required pharmacologic interventions, including nitroglycerin and dobutamine, to maintain hemodynamic stability.
- No perioperative myocardial morbidity or mortality was observed.
Implications:
- Laparoscopic cholecystectomy can be performed in patients with severe cardiac dysfunction, but requires careful hemodynamic monitoring and management.
- Anesthesiologists and surgeons should be prepared for significant hemodynamic shifts and potential need for pharmacologic support.
- Further research may explore optimized anesthetic and surgical strategies for this high-risk population.
Study Objective:
To evaluate the hemodynamic changes and need for pharmacologic interventions during laparoscopic cholecystectomy in patients with severe cardiac dysfunction.
Design:
Prospective open study.
Setting:
University hospital.
Patients:
17 ASA physical status III and IV patients with severe cardiac dysfunction undergoing elective laparoscopic cholecystectomy.
Interventions:
A standardized general anesthetic and surgical technique was used for all patients. In addition to routine monitoring, invasive hemodynamic monitoring included radial and pulmonary artery (PA) cannulation.
Measurements And Main Results:
Hemodynamic parameters were recorded prior to induction of anesthesia, 5 minutes after induction of anesthesia but prior to incision, 5 minutes after carbon dioxide (CO2) insufflation and head-up tilt, every 10 minutes after change of position, after deflation of the abdomen and return to supine position, and 10 minutes after attaining supine position. Need for any pharmacologic interventions [to maintain mean arterial pressure (MAP) < 100 mmHg and/or systemic vascular resistance (SVR) < 2,000 dynes sec/cm-5, and/or cardiac index (CI) > 1.5 L/min/m2] and the incidence of any myocardial morbidity and mortality was noted. CI decreased significantly (p < 0.05) following insufflation and remained low until exsufflation. MAP, SVR, and PA occlusion pressure increased significantly (p < 0.05) after CO2 insufflation. Three of the 17 patients required administration of nitroglycerin to maintain the MAP and SVR within the accepted limits, one of whom also required administration of dobutamine to maintain CI. There was no myocardial morbidity or mortality in the perioperative period.
Conclusion:
Laparoscopic cholecystectomy in patients with severe cardiac dysfunction results in significant hemodynamic changes.
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