LAPAROSCOPY —AN INVESTIGATION DURING SPONTANEOUS VENTILATION WITH HALOTHANE

Brit. J. Anaesth. (1972), 44, 685

LAPAROSCOPY—AN INVESTIGATION DURING SPONTANEOUS VENTILATION WITH HALOTHANE D. G. LEWIS, W. RYDER, N. BURN, J. T. WHELDON AND D. TACCHI SUMMARY

Diagnostic optical inspection of the abdominal contents via a telescope has been carried out using a variety of techniques since the beginning of the century (Jacobeus, 1910; Nordenloeft, 1912). The technique requires the creation of an artificial pneumoperitoneum and although other gases, e.g., air, oxygen and nitrous oxide, have been used in the past, of recent years in gynaecology, carbon dioxide has supplanted them (Palmer, 1947; Palmer and Palmer, 1950). The advantages of using carbon dioxide are declared to be a reduction in the incidence of gas embolism and a diminution of shoulder tip pain postoperatively. In addition the use of carbon dioxide allows the safe use of both diathermy for coagulation during biopsy and sterilization, and electronic flash in photography. A possible danger of carbon dioxide insufflation in laparoscopy was suggested by Desmond and Gordon (1970) and Hodgson, McClelland and Newton (1970) when patients anaesthetized with halothane are permitted to breathe spontaneously, as high levels of arterial carbon dioxide tension could be produced which are known to precipitate cardiac arrhythmias. The safety of such an anaesthetic technique, using D. G. LEWIS,* M.A., F.F.A.R.C.S.; W. RYDER,* F.F.A.R.C.S.; N. BURN,* A.I.S.T.,; J. T. WHELDON,* F.F.A.R.C.S.;

D. TACCHI,! M.D., F.R.C.O.G.; Department of Anaesthesia

University of Newcastle upon Tyne and Royal Victoria Infirmary, Newcastle upon Tyne, England. tDepartment of Obstetrics and Gynaecology, University of Newcastle upon Tyne NE1 4LF, England, and Royal Victoria Infirmary, Newcastle upon Tyne, England.

halothane with spontaneous ventilation, was evaluated in a large general hospital after a non-fatal cardiac arrest had occurred which was attributed to gas embolism. METHOD

Seventeen consecutive patients from the gynaecological waiting list for laparoscopy were investigated. Their mean age was 26 years (range 20-35) and their mean weight 58.5 + 15 kg. They were free from physical disability apart from that for which laparoscopy was performed. Fifteen patients were investigated for primary amenorrhoea and two patients were sterilized. The patients were premedicated with papaveretum and atropine in the customary dosage range, one hour before anaesthesia. Sleep was induced with 2.5% thiopentone and intubation facilitated by suxamethonium 50 mg. The patients were then allowed to breathe spontaneously using a Magill circuit and an efficient non-rebreathing valve. Anaesthesia was maintained with 2-3.5% halothane in a concentration just adequate to suppress reflex movements, the balance being oxygen. The anaesthetized patient was transferred to the operating table and placed in the lithotomy position. She was catheterized and examined bimanually. After the insertion of an insufflation cannula, a small bubble of gas was introduced through a periumbilical puncture with a Verres needle, the table being tilted into a head down position. The carbon dioxide for insufflation was both supplied and monitored using the apparatus manufactured by Drapier et Cie.,

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Seventeen patients undergoing routine laparoscopy, using carbon dioxide as the insufflating gas, were anaesthetized by a technique using halothane in oxygen and permitting spontaneous ventilation. The ventilatory variables and electrocardiographic changes were monitored continuously or at 2-3 min intervals. Little change in the ventilatory variables was noted when die abdomen was distended but they altered considerably after the gynaecological procedure had been completed. No cardiac arrhythmias occurred after carbon dioxide had been introduced into the peritoneal cavity. The possible causes of the cardiac irregularities seen when carbon dioxide insufflating gas is used for laparoscopy when spontaneous ventilation with halothane is used are discussed.

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Observed variables. Arterial carbon dioxide tension (PaCO2) was estimated at two min intervals from arterialized capillary specimens from an ear lobe, using the micro-Astrup apparatus and the interpolation nomogram of Siggaard-Andersen (1963). Minute volume (V) was measured at 2^-5 min intervals using a Wright respirometer (Wright, 1955) previously calibrated against an accurate dry gas meter using physiological flows. The respirometer was placed at the expiratory outlet of a nonrebreathing valve which had been tested for leakage. Mean expired carbon dioxide concentration (FECO2) was measured using a Uras-Braun Mark IV infrared analyzer and recorded continuously on an ultraviolet recorder. A mixing device was included in the expiratory line and experimentally it was demonstrated that after an abrupt change in carbon dioxide concentration mixing was complete within four respiratory cycles. Carbon dioxide output (Vco2) was calculated from minute volume and mixed expired carbon dioxide concentration after correction of the former to STPD. Pulse rate, systolic blood pressure, respiratory rate and operating theatre temperature were also recorded. Electrocardiographs were recorded continuously on magnetic tape in all patients from induction to the end of anaesthesia. RESULTS

For convenience, the time of anaesthesia was divided into three periods. Pre-insufflation lasted from induction of anaesthesia until the beginning of

insufflation. Insufflation was arbitrarily denned as the time from which carbon dioxide first entered the abdomen until the abdomen was compressed to expel carbon dioxide at the termination of the gynaecological procedure. Post-insufflation occupied the remainder of the time of anaesthesia. Postinsufflation terminated before anaesthesia was lightened, preparatory to the awakening of the patient. The period of insufflation varied in individual patients being of mean duration 14.2 min range 4-30 as demonstrated in figure 1. Means of the ventilatory variables were calculated at the end of the pre-insufflation phase, at the end of insufflation and twelve min into the post-insufflation phase. 70r

8

12

16

20

28

Time (min) FIG. 1. Paco2 during insufflation.

Records were kept for longer in individual patients. However, the reduction in numbers after twelve min post-insufflation made later means less representative, as the variables in some of the eliminated patients had returned to normal. Both the end insufflation and post-insufflation means were compared statistically with the mean before the start of insufflation for each of the variables of ventilatory state. The level of significance was 5%. The changes in the mean values of ventilatory variables are shown in table I and figure 2. The means were calculated at 2 min intervals by interpolation in figure 2 but as the duration of the insufflation phase was variable (mean 14.2 min, range 4-30) these averages were calculated in each case to fourteen minutes insufflation only.

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Paris. The tilt of the table was increased to a 30° Trendelenburg position and the abdomen slowly distended over three to four minutes with three litres of gas to a pressure of 20 mm Hg in order to reduce the risk of embolism. The needle was removed and a trochar and cannula inserted. No loss of gas occurred when the laparoscope replaced the trochar owing to a shutter mechanism. The intra-abdominal pressure was maintained by low flow supplementation. When visualization was complete, the abdomen was manually compressed, during realignment from the Trendelenburg position, to remove as much carbon dioxide as possible. As supplementation of gas was intermittent during the period of distension, slight fluctuations of intraabdominal pressure occurred.

LAPAROSCOPY—AN INVESTIGATION TABLE. I. The variations in ventilatory variables during COi laparoscopy in patients breathing spontaneously with halothane. End of preinsufflation

End of insufflation

12 min post-insufflation

52.9 5.3 3.69 1.35 3.15 3.35 102 38.5

57.5* 6.8 4.61 1.64 3.07 0.67 126 36.7

66.9* 17.8 5.79* 2.50 3.57* 0.53 167* 53.7

Mean PaC02 (mm Hg) S.D. VBTPS Mean S.D. Mean S.D. (%) Mean Vco 2 (ml/mln) S.D.

Although a significant difference of 4.6 mm Hg was seen in mean arterial carbon dioxide tension between the end of insufflation and the end of preinsufflation, this quantitative change during the insufflation phase was small. At twelve minutes postinsufflation the mean tension had risen a further 9.4 mm Hg. In individual patients much larger rises were recorded, but as peak values were attained at variable times in the post-insufflation phase, these are poorly reflected in any given mean calculation, but are nonetheless suggested by the large standard deviation (17.8 mm Hg). In one patient an arterial carbon dioxide tension of more than 100 mm Hg was noted twenty-seven minutes after the end of insufflation (Fig. 3).

PaCO 2 (mmHg) 525

V

BTPS

(l./min)

F§CO 2

20

VCO2

40

60

80

Time (min)

(ml/min) 140

FIG. 3. Changes of Paoo2 VBTPS, Ffico2 and Vco2 during laparoscopy; 41 kg, carbon dioxide input 6.75 1.

20

40

60

80

WO

Time (min) FIG. 2. Changes of mean Paoo2 VBTPS, FECO2 and Vco2 during laDaroscopy.

Significant differences were found between the post-insufflation mean and that at the end of preinsufflation for minute ventilation, mixed expired carbon dioxide concentration and carbon dioxide output although significance had not been attained by the end of insufflation. The above ventilatory variables were also measured in patients undergoing minor surgery in the

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•Denotes a significant difference from the mean at the end of pre-insufflation (P<0.05).

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DISCUSSION

Desmond and Gordon (1970) and Hodgson, McClelland and Newton (1970) suggested that carbon dioxide laparoscopy was unsafe if patients were allowed to breathe spontaneously when anaesthetized with nitrous oxide, oxygen and halo thane. They advocated hyperventilation using a relaxant technique as this would reduce the hazards produced by high arterial carbon dioxide tensions and low arterial oxygen tensions. Oxygen tensions were not investigated in this study as oxygen rich anaesthetic mixtures were used making hypoxaemia unlikely. A marked fall of arterial oxygen tension was reported by Desmond and Gordon (1970) in a spontaneously ventilating patient anaesthetized by nitrous oxide, oxygen and halothane. In the present study arterial oxygen tensions would be considered unlikely to fall as minute volume rose by 1-2 l./min. The introduction of large volumes of carbon dioxide into the peritoneal cavity makes it likely that arterial carbon dioxide tensions will be raised. It has been convincingly demonstrated that high carbon dioxide tensions can cause cardiac arrhythmias. Black et al. (1959) investigated the relationship between end tidal carbon dioxide tension and cardiac arrhythmias in women who were allowed to breathe spontaneously whilst anaesthetized with halothane and oxygen. End tidal carbon dioxide tension was raised by incrementally increasing the

inspired carbon dioxide concentration during an experiment in which the patient did not undergo surgery. They reported some variations in the level of end tidal carbon dioxide tensions at which cardiac arrhythmias occurred, but this "threshold" was relatively constant for individual patients. Several factors could contribute to raising the carbon dioxide tension in carbon dioxide laparoscopy with halothane anaesthesia if spontaneous ventilation is permitted. These are the depression of ventilation by premedicant and anaesthetic drugs; absorption of carbon dioxide from the peritoneal cavity; and impairment of ventilation by mechanical factors such as abdominal distension and the use of a steep Trendelenburg position. The effects of general anaesthesia on the ventilatory state can be observed in isolation in the preinsufflation phase. Arterial carbon dioxide tension rose to levels which were similar to those reported by Severinghaus and Larsen (1965) in unpremedicated spontaneously ventilating volunteers anaesthetized with halothane and oxygen. Carbon dioxide output was only 65-69% of the predicted normal values calculated from the standards of Harris and Benedict (1919) for conscious women, but were similar to those recorded in women investigated by Nunn and Matthews (1959) where the low levels were attributed to irregular breathing and hypoventilation (Severinghaus and Larsen, 1965). The ventilatory variables in the laparoscopy patients during the pre-insufflation phase were found to be similar to those of patients undergoing minor surgery and anaesthetized with the same technique. Thus, although general anaesthesia produced a rise in carbon dioxide tension, it was not of major importance. Only small rises in carbon dioxide tension and carbon dioxide output were seen when the abdominal cavity was distended with gas. This suggests that only a small amount of carbon dioxide was absorbed from the peritoneal cavity. The absorption of a gas from the peritoneal cavity depends on its diffusibility and the perfusion of the walls of that cavity (Piiper, 1965). Diffusion of carbon dioxide is unlikely to be impaired because its relative diffusibility is twenty times that of air and, in addition, it can combine with the alkaline buffers of blood (Teschendorf, 1951). This author reported that carbon dioxide is absorbed much more slowly from the peritoneal cavity than from the pleural cavity. This suggests that the limiting factor in the

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steep Trendelenburg position. These scores were similar to those seen in the pre-insufHation period in patients undergoing laparoscopy. Cardiac arrhythmias were noted in two of the patients in this series. In one patient two episodes of trigeminy were recorded, the longer of which lasted thirty seconds and occurred immediately after intravenous injection of suxamethonium. In the second patient two periods of ventricular extrasystoles were recorded, both of thirty sec duration. These episodes occurred in the pre-insufflation phase, no cardiac arrhythmias being detected once induction of a carbon dioxide pneumoperitoneum had commenced. In this series the electrocardiographic changes resulting from an artificial pneumoperitoneum were not observed (Ellwood, Piltz and Potter, 1940). There was little change in the other cardiovascular variables observed, pulse rate and systolic blood pressure remaining steady. The mean amount of carbon dioxide introduced into the peritoneal cavity was 5.09 + 2.23 1. (range 1.5-8.98).

LAPAROSCOPY—AN INVESTIGATION

of carbon dioxide tensions occur after the completion of anaesthesia, artificial ventilation will confer no greater advantage than spontaneous ventilation. Indeed, if any residual curarization remains, it will create a greater hazard than spontaneous ventilation. In the literature of laparoscopy few accounts of cardiac irregularity are recorded. In the rare cases described they have not been described in detail or accurately related to the time of insufflation. Hodgson, McClelland and Newton (1970) described one case in which laparoscopy had to be abandoned because of severe cardiac arrhythmias. This suggests that the arrhythmias occurred early in the insufflation phase when high arterial carbon dioxide tensions are unlikely according to the present study. Desmond and Gordon (1970) described eight minutes of ventricular arrhythmias in one patient in whom the arterial carbon dioxide tension was not greater than 34 mm Hg. The above evidence suggests that raised arterial carbon dioxide tension is unlikely to be responsible for the cardiac irregularities which have undoubtedly occurred in laparoscopy. Of other possible explanations, carbon dioxide embolism must be considered for it is likely that if it is responsible it will produce cardiac arrhythmias early in the insufflation phase during induction of artificial pneumoperitoneum. Indeed a possible case of gas embolism provided the impetus to this study and a further case was described by Kelman and colleagues (1971). The former case occurred in a plump nineteenyear-old girl who was submitted to laparoscopy during investigation of a possible Stein-Leventhal syndrome. Nitrous oxide, oxygen and halothane were used for maintenance of anaesthesia but, apart from this change, a technique similar to that described in the present study was used. When the pneumoperitoneum was induced the gas was noted to be flowing freely and slight distension of the abdomen occurred. The patient suddenly became cyanosed and the pulse could not be palpated. No heart sounds could be heard on auscultation of the chest. External cardiac massage was instituted immediately and the pulse was restored in 2-3 min. An electrocardiogram recorded immediately after restoration of the pulse showed no abnormality and no "machinery" murmur was heard. The laparoscopy was abandoned. Although consciousness was impaired, on clinical assessment eight hours later, the patient was apparently normal. A tentative diagnosis of carbon dioxide embolism was made. It is dubious whether carbon dioxide embolism

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absorption of carbon dioxide is local perfusion. In carbon dioxide laparoscopy the maintenance of an intra-abdominal pressure of 20 mm Hg would further restrict the capillary bed. Therefore a delay might occur in absorption of carbon dioxide from the peritoneal cavity which could prevent the anticipated rise in arterial carbon dioxide tension during the insufflation phase. Marked rises in the ventilatory variables occurred on release of the intra-abdominal tension which further supports this contention. The steep Trendelenburg position which was used in combination with lithotomy in this procedure is known to impair ventilation (Wood-Smith, Home and Nunn, 1961). Alexander, Noe and Brown (1969) found that abdominal distension and the steep Trendelenburg tilt impaired pulmonary mechanics in laparoscopy patients. The impairment of ventilation should raise carbon dioxide tension. However, since this occurs only in the insufflation period when only a small rise of carbon dioxide tension occurred, it is probably of minor importance. On the evidence of this study, cardiac arrhythmias are more likely to occur in the post-insufflation phase, if a raised arterial carbon dioxide tension is regarded as their chief antecedent in laparoscopy. In only one patient did the arterial carbon dioxide tension reach 70 mm Hg in the insufflation phase, but in all patients it exceeded 75 mm Hg at some time during the post-insufflation period. In both the insufflation and post-insufflation phases no cardiac irregularities were noted, despite the arterial carbon dioxide tension exceeding 100 mm Hg in one patient in the latter phase. In a minority of patients these high carbon dioxide tensions occurred late in the postinsufflation phase when the patients would ordinarily have left the operating theatre if anaesthesia had been terminated immediately after the conclusion of the operative procedure. This is perturbing as it is conceivable that high carbon dioxide tensions could develop in some cases in the lift or on the ward, producing cardiac arrhythmias and cardiovascular collapse. Artificial ventilation is considered safer than spontaneous ventilation as high arterial dioxide tensions can be more readily controlled by hyperventilation (Desmond and Gordon, 1970; Hodgson, McClelland and Newton, 1970). If the laparoscopy patient recovers from anaesthesia soon after completion of the operative procedure, the main effect of hyperventilation will be seen during the insufflation period when carbon dioxide tensions are not unusually high (mean 57.4 mm Hg). If high levels

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REFERENCES

Alexander, G. D., Noe, F. E., and Brown, E. M. (1969). Anesthesia for pelvic laparoscopy. Anesth. Analg. Curr. Res., 48, 14. Black, G. W., Linde, H. W., Dripps, R. D. and Price, H. L. (1959). Circulatory changes accompanying respiratory acidosis during halothane (Fluothane) anaesthesia in man. Brit. J. Anaesth., 31, 238. Burko, H., and Klatte, E. C. (1967). Renewed interest in gases for contrast roentgenography. Amer. J. Roentgenol., 99, 645. Desmond, J. and Gordon, R. A. (1970). Ventilation in patients anaesthetized for laparoscopy. Canad. Anaesth. Soc. J., 17, 378. Ellwood, B. J., Piltz, G. F. and Potter, B. P. (1940). Electrocardiographic observations on pneumoperitoneum. Amer. Heart J., 19, 206. Handley, R. (1955). Peritoneoscopy. Postgrad. Med. J. J., 2, 1211. Handley R., and Nurick, A. W. (1956). Peritoneoscopy: an evaluation with report on 136 cases. Brit. med. J., 2, 1211. Harris, J. A. and Benedict, F. G. (1919). A Biometric Study of Basal Metabolism in Man. Publication 279 of Carnegie Institution of Washington. Hipona, F. A., Ferris, E. J. and Pick, R. (1969). Capnocavography. A new technic for examination of inferior vena cava. Radiology, 92, 606. Hodgson, C , McClelland, R. M. A. and Newton, J. R. (1970). Some effects of peritoneal insufflation of carbon dioxide at laparoscopy. Anaesthesia, 25, 382. Jacobeus, H. C. (1910). Ueber die Moglichkeit die Zysloskopie bei Untersuchung Siroser Hohlungen an Zuwenden. Munch, med. Wscher., 58, 2090. Johnston, I. D., and Rodgers, H. W. (1964). Peritoneoscopy as an aid to diagnosis. Gut, 5, 485. Kelman, G. R., Benzie, R. J., Gordon, N. L. M., Smith, I. and Swapp, G. (1971). Paper presented at Anaesthetic Research Society meeting in Belfast. Nordenloeft, S. (1912). Ueber Endoskopie Geschlossener Cavitaten Mittelst Meines Trokart—Endoskops. Verh. dtsch. Ges. Chir, 42, 78. Nunn, J. F. and Matthews, R. L. (1959). Gaseous exchange during halothane anaesthesia: the steady respiratory state. Brit. J. Anaesth., 31, 330. Oppenheimer, M. J., Durant, T. M. and Lynch, P. (1953). Body position in relation to venous air embolism and its associated cardiovascular respiratory changes. Amer. J. med. Sci., 225, 362. Palmer, R. (1947). Instrumentation et Technique de la Coelioscopie Gynecologique. Gynec. et Obstet., 46, 420. Palmer, R., and Palmer, E. (1950). La Sterilite Involontaire, pp. 222-252, Paris: Masson. Paul, R. E., Durant, T. E., Oppenheimer, M. J. and Stauffer, H. M. (1957). Intravenous carbon dioxide for intracardiac gas contrast in the roentgen diagnosis of pericardial effusion and thickening. Amer. J. Roentgenoh, 78, 224. Piiper, J. (1965). Physiological equilibria of gas cavities in the body, in Fenn, W. O. and Rahn, M. (eds). Handbook of Physiology. Section 3: Respiration 2, p. 1205. Roger, M. (1952). Valeur de la Laparoscopie; Resultats de 600 observations. Sem. Hop. Paris, 28, 2343. Ruddock, J. C. (1957). Peritoneoscopy: a critical clinical Review. Surg. Clin. N. Amer., 37, 1249.

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is the true explanation of this episode. Burko and Klatte (1967) showed that carbon dioxide is at least five times as safe as air in dogs. Large series have been published by general surgeons in which embolism did not occur (Handley, 1955; Ruddock, 1957) although air was used as the insufflating medium and the potentially more dangerous reverse Trendelenburg position was used. Indeed, on surveying the literature only seven deaths from air embolism were reported between 1950 and 1964 when air was the insufflating medium (Roger, 1952; Handley and Nurick, 1956; Zoeckler, 1958; Johnston and Rodgers, 1964). Radiologists rapidly inject 50-100 ml of carbon dioxide intravenously in man (Paul et al., 1957; Viamonte, 1962; Shuford et al., 1966 and Hipona, Ferris and Pick, 1969). In these cases the risk of embolism was reduced by maintaining the patients in the left lateral decubitus position for five minutes (Oppenheimer, Durant and Lynch, 1953). Scatcliff, Kummer and Jansen (1959) after administering a similar injection to fifteen patients restored them to a supine position within 20-30 sec of completion of the injection. No untoward signs were reported apart from a paroxysmal coughing attack in an emphysematous patient which was probably coincidental. This evidence suggests that carbon dioxide embolism is an unlikely explanation of cardiac arrhythmias and cardiovascular collapse when the customary dosages used in laparoscopy are considered. The cause of cardiac irregularities and cardiovascular collapse in carbon dioxide laparoscopy in patients breathing spontaneously using halothane anaesthesia is obscure. Arrhythmias or cardiovascular collapse appear to occur more commonly in the early insufflation phase. If this is true it seems unlikely to result from raised carbon dioxide tensions. If the usual clinical volumes and rates of carbon dioxide are used during insufflation, carbon dioxide embolism seems equally unlikely. It is possible that pain reflexes, caused by either the solution of carbon dioxide in the peritoneal fluid or by stretching the mesentery on introduction of the gas, may be responsible. The highest tensions of carbon dioxide in this investigation were seen after completion of the surgical procedure when the intra-abdominal pressure had been released. If these occurred after completion of anaesthesia, cardiac arrhythmias would result, which would occur independently of the ventilatory technique used during anaesthesia. Further investigation of the postoperative period is •necessary.

BRITISH JOURNAL OF ANAESTHESIA

LAPAROSCOPY—AN INVESTIGATION

LAPAROSCOPIE; UNE INVESTIGATION DURANT LA VENTILATION SPONTANEE AVEC HALOTHANE SOMMAIRE

Dix-sept patients subissant une laparoscopie de routine, avec anhydride carbonique pour rinsufflation, ont ete anesthesies, a l'aide d'une technique utilisant halothane dans oxygene et permettant une ventilation spontanee. Les variables de la ventilation et les modifications electrocardiographiques ont ete controlees continuellement ou a des intervalles de 2-3 minutes. Peu d'alteration des variables ventilatoires a ete notee lorsque l'abdomen etait distendu mais elles changerent considerablement quand la procedure gynecologique avait ete completee. II n'y eut pas d'arythmies cardiaques apres insufflation de l'anhydride carbonique dans la cavite peritoneale. Les auteurs discutent les causes possibles

des irregularites cardiaques vues lorsque l'anhydride carbonique est utilise pour 1'insufSation a la laparoscopie quand une ventilation spontanee aves halothane est appliquee. DIE LAPAROSKOPIE—EINE UNTERSUCHUNG WAHREND EINER SPONTANATMUNG VON HALOTHAN ZUSAMMENFASSUNG

Bei 17 Patienten, die sich einer routinemassigen Laparoskopie mit Kohlendioxid als Insuffiationsgas unterzogen, wurde eine Narkose mit Halothan in Sauerstoff bei Spontanatmung durchgefuhrt. Die respiratorischen Messgrossen und elektrokardiographische Veranderungen wurden entweder kontinuierlich oder in 2-3-miniitigen Abstanden angezeigt. Wahrend der Insufflation des Abdomens traten nur geringe Veranderungen der Atemfunktionen auf, die sich jedoch nach Beendigung eines gynakologischen Eingriffes erheblich anderten. Kardiale Arrhythmien traten nach Einbringen von Kohlendioxid in die Bauchhohle nicht auf. Die moglichen Ursachen kardialer Unregelmassigkeiten, wie man sie bei Verwendung von Kohlendioxid als Insuffiationsgas fur die Laparoskopie sieht, wenn Halothan spontan eingeatmet wird, werden diskutiert. LAPAROSCOPIA—UNA INVESTIGACION DURANTE LA VENTILACION ESPONTANEA CON HALOTANO RESUMEN

Diecisiete pacientes sometidos a laparoscopia rutinaria, utilizando anhidrido carb6nico como gas de insuflacion, fueron anestesiados por una tecnica utilizando halotano en oxigeno y permitiendo una ventilaci6n espontanea. Las variables ventilatorias y cambios electrocardiograficos fueron monitorizados continuamente o a intervalos de 2-3 min. Fue observado poco cambio en las variables ventilatorias cuando el abdomen fue distendido, pero se modificaron considerablemente despues de haber sido terminada la intervencion ginecolbgica. No hubo arritmias cardiacas despues de la introduccion de anhidrido carbdnico dentro de la cavidad peritoneal. Son discutidas las causas posibles de las irregularidades cardiacas observadas cuando el anhidrido carbonico es utilizado como gas de insuflacion para la laparotomia en casos con ventilacion espontanea con halotano.

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Scatcliff, J. H., Kummer, A. J. and Jansen, A. H. (1959). Diagnosis of pericardia! effusion with intracardial carbon dioxide Radiology, 73, 871. Severinghaus, J. W., and Larsen C. P. jr. (1965). Respiration in anesthesia, in Fenn, W. O. and Rahn, M. (eds): Handbook of Physiology, Section 3: Respiration, 2, pp. 1227-1229. Shuford, W. H., Sybers, R. G., Acker, J. J. and Weens, H. S. (1966). A comparison of carbon dioxide and radiopaque angiocardiographic methods in the diagnosis of pericardial effusion. Observations regarding Fluid shift in the pericardial space. Radiology, 96, 1064. Siggaard-Andersen, O. (1963). The acid base status of blood. Scand. J. clin. Lab. Invest., 15, Supplement 70. Teschendorf, W. (1951). Ober die Verwendung Schnell Resorbierbarer Gase in der Rontgen-diagnostik. Ada radiol. (Stockh.), 36, 297. Viamonte M. Jr, (1962). Co, angiocardiography; improved technique and results, Amer. J. Roentgenol., 88, 31. Wood-Smith, F. F., Home, G. M., and Nunn, J. F. (1961). Effect of posture on ventilation of patients anaesthetized with halothane. Anaesthesia 16, 340. Wright, B. M. (1955). A respiratory anemometer. J. Physiol. (Lond.), 127, 25P. Zoeckler, S. J. (1958). Peritoneoscopy: a revaluation. Gastroenterology, 34, 969.

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