¹Junior Resident, ^3,6Assistant Professor, ⁴Professor, ⁵Associate Professor, Department of Anaesthesia & Intensive Care}

{⁷Professor, Department of General Surgery} PGIMER, Chandigarh, INDIA.

²Junior Resident, Department of Obstetrics & Gynaecology, Kamla Nehru Hospital, Shimla, Himachal Pradesh, INDIA.

Email: varshasapehia@gmail.com

RESULTS

Total 30 patients were enrolled in this prospective trial; 15 in each group. (Study and control group). The mean age of patients are 55.6 years and 36.6 years in study and control group, respectively and difference was statistically significant. Sex distribution: In control group, male: female distribution is 1:1.2; while in the study group, male: female distribution is 1:4, and difference was statistically significant. Other parameters like weight, height, BMI, BSA and duration of surgery were comparable in both groups and difference was not statistically significant.

Table 1: General characteristics of both groups

From T1 to T2, the decrease in mean HR is 6.5% in the study group as compared to 9.2% decrease in control group while at T3 clinically insignificant changes in mean HR from T2 are noticed in both the groups. On intragroup statistical analysis, in the control group a statistically significant fall in HR is noticed at T2 and T4 from T1.

Table 2: Heart rate in the two groups

The mean values of mean arterial pressure in both the groups were comparable at the predefined time points during the study except at T5. From T1 to T2, the fall in mean MAP was 9.7% in the study group as compared to 22.3% decrease in control group while from T2 to T3, 32.5% and 23.3% increase in MAP was seen in the study and control group respectively.

Table 3: Mean arterial pressure in the two groups

The increase in mean central venous pressure was from T1 to T2, 29.3% in the study group as compared to a 1.3% decrease in control group. The central venous pressure has an increasing trend from T2 to T4 in both the groups. Mean CVP values decrease from T4 to T5 in both the groups and reach values approximately similar to the T1 levels.

TABLE 4: Mean central venous pressure in the two groups

The mean stroke volume variation in both the groups was comparable at the predefined time points during the study except at T2. From T1 to T2, no change in mean SVR is seen in the study group as compared to 7.2% fall in the control group while from T2 to T3 and T4, there was an increase in the mean SVR in both groups. The mean SVR values at T5 return to the approximately the T1 levels after CO2 exsufflation in both the groups.

Table 5: Mean stroke volume variation in the two groups

mean cardiac output in both the groups was comparable at the predefined time points during the study except at T3. From T1 to T2, the fall in mean CO is 15.9% in the study group as compared to 19.7% decrease in control group while at T3 9.7% (from T2) fall in CO is noticed in study group as compared no fall in the control group.

Table 6: Mean cardiac output in the two groups.

Out of the 15 patients in the study group, 4 patients had episodes of hypotension requiring intervention. Only 1 patient in the study group had an episode of bradycardia at T2 requiring intervention. The patient in the control group had no intraoperative adverse event during the study. There were no episodes of clinically significant hypertension, tachycardia and arrhythmias requiring intervention in both the groups. No significant complications occurred during immediate postoperative period as well as during the hospital stay. All control groups patients were discharged from hospital on the evening of surgery. Amongst the study group patients, 5 were discharged on the POD 1 and two were discharged on POD2 of surgery. On 3 month follow up of these patient (telephonically), no mortality or morbidity has been recorded.

DISCUSSION

Laparoscopic cholecystectomy minimizes abdominal incision and therefore pulmonary function and diaphragmatic function remain preserved. Laparoscopic cholecystectomy decreases the incidence of postoperative ileus, helps early ambulation, has economic benefits, helps early ambulation with shorter hospital stay , early return to work and normal daily activities.^3,4 Pneumoperitoneum stimulate a neuro-hormonal stress response which lead to increases heart rate, mean arterial blood pressure and systemic vascular resistance.² Myocardial oxygen demand is increased by these factors having deletiorus effects on patients having cardiac dysfunction.⁶ Venous return and preload is decreased by increased intra-abdominal pressure and reverse Trendelenburg position , and it increases afterload which would eventually increase cardiac burden. These could precipitate cardiac ischemia or infarction. Ischemic heart disease patients have more chances of having arrhythmias due to CO₂ pneumoperitoneum⁴.In most of the literature pneumoperitoneum effects on cardiovascular system has been studied on healthy subjects who can tolerate it well without much complications.⁷ With pneumoperitoneum the variation in cardiovascular parameters will depend on the patient's intravascular volume, the ventilatory technique , anesthetic agents employed, rate insufflations on the intra-abdominal pressure attained , amount of CO₂ absorbed and patient characteristics.⁸ Intensive intraoperative monitoring and vigilance in the anesthetic management is of utmost importance for a smooth perioperative course in patients with cardiac dysfunction. This requires a thorough knowledge into the effect of pneumoperitoneum and reverse Trendelenburg positioning on the cardiac physiology especially with respect to patients with a diseased myocardium. According to the demographic data, the patients in the study group belong to a significantly older age group (55± 7 years) as compared to those in the control group (36 ± 10 years). This difference can be very well explained by the fact that incidence of LV systolic dysfunction and hypertension increases significantly with age.⁹ Patients in the study per se are predominantly females (72%). A population based study done in the north Indian population confirms a greater prevalence of cholecystitis in females as compared to males.¹⁰ Rest of the demographic parameters like weight, height, BMI and BSA were comparable in both the groups. The duration of pneumoperitoneum during the surgery was also comparable in the two groups. Kelman et al.,¹¹ noted that cardiac filling pressures can be increased effectively with moderate increase in IAP (up to 25 cm H₂0). When IAP reached 40 cm H2O tachycardia, reduced CVP, hypotension and decreased cardiac output was there. There is increased cardiac output at lower IAP possibly due to increased cardiac filling pressures, which can be partially due to mechanical factors, and partially due to constriction of capacitance vessels caused by sympathetic response and effects on cardiac efferent sympathetic activity due to hypercarbia.¹² Hein et al.,¹³ in studied 17 patients of ASA III/IV with severe cardiac dysfunction underwent laparoscopic cholecystectomy . They noticed that significantly decreased in CI (p < 0.05) following insufflation and remained low until exsufflation. After CO₂ insufflation MAP, SVR, and PA occlusion pressure increased significantly (p < 0.05) .Required administration of nitroglycerin to maintain the MAP and SVR in three out of 17 patients. In another similar study, Dhoste et al.,¹⁴ noted that after induction patients had cardiovascular depression and after post peritoneal insufflation, an improvement of cardiovascular function with increases in cardiac index (+19%), heart rate (+21%), MAP (+19%). They hypothesized this effect to be as a result of a sympathetic stimulation during creation of pneumoperitoneum.¹⁴Various noninvasive monitoring techniques are available to obtain a better insight into the pathophysiological effects of creation of pneumoperitoneum. TTE is a non-invasive, cost effective technique which gives us a quick, repeatable and reliable real time image of the ongoing changes in cardiac function as well as helps us in early diagnosis of the cause of any adverse hemodynamic event encountered during surgery. It also serves as a good guide in perioperative management¹⁵. Although limitations like poor cardiac window and difficult access following placement of surgical drapes may limit measurements in all the various echocardiographic views.

CONCLUSION

Present study showed that laparoscopic cholecystectomy may be safely done in cardiac patients with moderate to severe left ventricular systolic dysfunction patients under the supervision of an experienced consultant anaesthesiologist. Optimization of cardiac status, administered of balanced anaesthesia and 10-12 mmHg pressure pneumoperitoneum are essential steps for patients’ safety. Life threatening complications are low and can be easily managed in hospital with adequate cardiology support.

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