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

Table 1: Demographic characteristics of both groups

The mean HR values, decrease in mean HR was 6.5% On intragroup statistical analysis, no significant change in mean HR is seen at T2, T3, T4 or T5 from T1 was noted.

Table 2: Heart rate at the defined time points of the study.

From T1 to T2, the fall in mean MAP was 9.7% while from T2 to T3, 32.5% increase in MAP was seen. On intragroup statistical analysis, no significant change in mean MAP was noted.

Table 3: Mean arterial pressure at defined time points of the study

From T1 to T2, the increase in mean CVP was 29.3% and mean CVP values decrease from T4 to T5 and reach values approximately similar to the T1 levels. On intragroup statistical analysis, significant increase in mean CVP was seen at T3, T4 from T1.

Table 4: Mean CVP at the defined time points of the study.

From T1 to T2, no change in mean SVR was seen, while from T2 to T3 and T4, there was an increase in the mean SVR, mean SVR values at T5 return to the approximately the T1 levels after CO2 exsufflation.

Table 5: Mean SVR at the defined time points of the study.

From T1 to T2, the fall in mean CO was 15.9% while at T3 9.7% (from T2) fall in CO was noticed and the CO does return to similar pre-induction T1 values at T5.

Table 6: Mean cardiac output at the defined time points of the study.

The mean EtCO2 values were statistically significant when compared from P1 values.

Table 7: Mean EtCO2 in the two groups at the defined time points of the study.

The PaCO2 values were comparable between predefined time points in the study.

TABLE 8: Mean PaCO2 in the two groups at the defined time points of the study.

Out of the 15 patients in the study group, 4 patients had episodes of hypotension, 1 patient in had an episode of bradycardia requiring intervention. No significant complications occurred during immediate postoperative period as well as during the hospital stay. On 3 month follow up of these patient (telephonically), no mortality or morbidity has been recorded.

DISCUSSION

Pneumoperitoneum stimulate a neuro-hormonal stress response which lead to increases heart rate, mean arterial blood pressure and systemic vascular resistance.¹ Myocardial oxygen demand is increased by these factors having deletiorus effects on patients having cardiac dysfunction.⁷ 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. 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 The hemodynamic consequences of intraoperative hypercarbia were addressed by Rasmussen et al. In a study of 12 patients with ischemic heart disease in whom PaCO₂ levels reached to 55-65 mmHg and resulted in a significant increase in heart rate, systolic blood pressure and cardiac output .It was also suggested the two- to threefold increase in plasma catecholamine concentrations due to sympathetic nervous system stimulation because of hypercarbia.⁹According to the demographic data, the patients belong to a significantly older age group (55± 7 years), which can be very well explained by the fact that incidence of LV systolic dysfunction and hypertension increases significantly with age.¹⁰ 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. ¹¹ Dhoste et al.,¹² in a similar study evaluated the hemodynamic and respiratory changes during laparoscopic cholecystectomy in patients aged >75 years, ASA III category and concluded that the main cardiovascular depression was noted after induction of anesthesia¹⁴. In their study the CI dropped by 41%, MAP by 27% while the HR by 20% from the baseline value. The fall in these hemodynamic parameters is greater as compared to observations in our study. This difference in results could be because of titrated and graded induction of anesthesia, along with rescue pharmacological interventions done to maintain the hemodynamic parameters. We relied on echocardiographic parameters for measurement of CO; a pulmonary artery catheter was utilized by Dhoste et al. Various 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 management.¹³ Tools like transthoracic echocardiography and dynamic fluid responsiveness monitoring using IABP or FloTrac (Edwards Life Sciences, Irvine, CA, USA) done perioperatively come in handy in these clinical scenarios. Present study intends to project that patients with moderate to severe systolic dysfunction can also undergo cholecystectomy using the laparoscopic technique keeping in mind the various changes in cardiac output and different stages of the surgery. A tailored anaesthetic technique keeping in mind the physiological changes of pneumoperitoneum, limited pneumoperitoneum time, and anesthetic as well as surgical expertise play a very important role in achieving stable hemodynamics perioperatively. The expertise of surgeon (same surgeon performing all the procedures) and an average time of pneumo-peritoneum of 29 minutes significantly reduce the duration of exposure of the patients with impaired left ventricular systolic function to the deleterious effects of pneumoperitoneum.

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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