Mustafa AZİZOĞLU, Süleyman MEMİŞ, Funda BARGU, İlkay SAYDERE, Handan BİRBİÇER, Gülhan ÖREKİCİ TEMEL

5 cm H2O PEEP uygulanan laparoskopik kolesistektomilerde serebral oksijenasyonun kan gazları ve hemodinami ile ilişkisi

GİRİŞ ve AMAÇ: Pnömoperitonyumun hemodinamik ve solunumsal parametreler üzerine olumsuz etkileri olabilmektedir. Serebral oksijenasyon, parsiyel arteriyel CO2 basıncı (PaCO2) temel belirleyici olmakla birlikte birçok faktörden etkilenir. Bu çalışmada 5 cmH2O pozitif end ekspiratuar basınç (PEEP) uygulaması ile laparoskopik kolesistektomilerde CO2 insüflasyonu ve baş yukarı pozisyonun hemodinamik parametreler ve serebral oksijenasyon üzerine etkilerini araştırdık. YÖNTEM ve GEREÇLER: Anestezi risk grubu ASA I - II olan, 18-65 yaş arası 40 hasta çalışmaya dahil edildi. Anestezi indüksiyonundan sonra, 5 cmH2O PEEP uygulandı ve abdomen CO2 ile insufle edildi. Hastalar 15 ° baş pozisyonunda opere edildi. BULGULAR: Pnömoperitonyum peryodu ile karşılaştırılınca, desüflasyon sonrası dönemde kardiyak debinin (CO) arttığı gözlendi (sırasıyla 5.08 ± 0.95 ve 5.80 ± 1.39; p <0.05). Diğer hemodinamik parametrelerde veya serebral oksijenasyon seviyelerinde değişiklik yoktu. Pnömoperiton periyodunda PaCO2 ve end-tidal CO2 (EtCO2) seviyelerinde yükselme saptandı (PaCO2 = 33.37 ± 4.97, 36.77 ± 3.91 ve 39.35 ± 3.51 mmHg ve EtCO2 = 31.52 ± 2.80, 33.95 ± 3.38 ve 35.72 ± 2.92 mm-Hg; insuflasyon öncesi, insüflasyondan 5 ve 20 dakika sonra, p <0.05). TARTIŞMA ve SONUÇ: Laparoskopik kolesistektomi sırasında 5 cmH2O PEEP uygulamasının serebral oksijenasyonu arttırmadığı, fakat insüflasyon sonrası bazal değerlerin korunmasına katkıda bulunabileceği kanısına varıldı. Sıvı uygulama stratejisi ve opioid kullanımı, stabil hemodinamik durumun sağlanmasında önemlidir. Buna ek olarak PaCO2 düzeyinde ılımlı yükselme serebral oksijenasyonun korunmasına katkıda bulunabilir.

Anahtar Kelimeler:

laparoskopik kolesistektomi, pozitif basınçlı solunum, kan sağlama, yakın kızıl-ötesi spektroskopi, kan gazı analizi

Cerebral oxygenation and its relation with blood gases and haemodynamic parameters in laparoscopic cholecystectomy with 5 cm H2O PEEP

INTRODUCTION: Pneumoperitoneum application during abdominal surgeries can have negative effects on haemodynamic and respiratory parameters. Cerebral oxygenation level is influenced by many factors; the partial arterial CO2 pressure (PaCO2) level is the main determinant factor among them. We investigated the effects of CO2 insufflation and the head-up position on haemodynamic parameters and cerebral oxygenation levels during laparoscopic cholecystectomy with the application of 5 cmH2O positive end–expiratory pressure (PEEP). METHODS: 18-65 years old, forty patients with an ASA physical status of I–II were included in the study. After anaesthesia induction, 5 cmH2O PEEP was applied and CO2 was insufflated into the abdominal space. Patients were operated in the 15° head-up position. RESULTS: Mean cardiac output was observed to be significantly higher after desufflation (5.80 ± 1.39) as compared to the initial values prior to the pneumoperitoneum application (5.08 ± 0.95). (p< 0.05)). There was no significant change in other haemodynamic parameters or cerebral oxygenation levels. PaCO2 and end-tidal CO2 (EtCO2) levels significantly increased during the pneumoperitoneum period (PaCO2 = 33.37 ± 4.97, 36.77 ± 3.91, and 39.35 ± 3.51 mmHg, and EtCO2 = 31.52 ± 2.80, 33.95 ± 3.38, and 35.72 ± 2.92 mmHg; before, at 5 and 20 min after insufflation respectively; p < 0.05). DISCUSSION AND CONCLUSION: Application of 5 cm H2O PEEP does not improve the cerebral oxygenation but may contribute to preservation of baseline values with stable haemodynamic status after insufflation during laparoscopic cholecystectomy. Fluid administering strategy and using opioids are important to achieve stable haemodynamic condition. In addition, mild increased PaCO2 levels may contribute to preserving cerebral oxygenation.

Keywords:

laparoscopic cholecystectomy, positive end expiratory pressure (PEEP), blood supply, near infrared spectroscopy (NIR Spectroscopy), blood gas analysis,

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