Does pneumoperitoneum with different gases, body positions, and intraperitoneal pressures influence renal and hepatic blood flow?

Department of Surgery, Charité, Humboldt University, Berlin, Germany.
Surgery (Impact Factor: 3.38). 02/1997; 121(2):206-11. DOI: 10.1016/S0039-6060(97)90291-9
Source: PubMed


Because of the well-known negative effects of carbon dioxide pneumoperitoneum on the hemodynamic and respiratory system, it was questionable how pneumoperitoneum may affect hepatic and renal blood flow. Therefore the influences of different gases, different intraperitoneal pressures, and different body positions on hepatic and renal blood flow were investigated in a porcine model.
Cardiac and hemodynamic function were monitored by means of implanted catheters in the pulmonary artery and the femoral vein and artery. Renal and hepatic blood flow were recorded with a transonic volume flow meter placed at the renal and hepatic arteries and the portal vein. Eighteen animals were randomly assigned to receive one of three insufflation gases (carbon dioxide [CO2], argon, or helium. After baseline recording, one of three intraperitoneal pressures (8, 12, or 16 mm Hg) and one of three body positions (supine head up, or head down) were randomly chosen. After an adaptation time of 15 minutes, all data were recorded for 15 minutes. This was repeated until all nine combinations had been investigated. The end points of the study were blood flow in the hepatic and renal arteries and the portal vein, cardial output, systemic vascular resistance, and central venous pressure.
Total liver blood flow was reduced on relation to intraabdominal pressure, head-up position, and argon insufflation. Arterial hepatic blood flow was reduced by the head-up position and argon insufflation. Portal venous blood flow decreased with the pig in the head-up position, with increased intraabdominal pressure, and argon insufflation. Renal blood flow was reduced by the head-up position and increased pressure. There was no correlation (p < 0.6) between systemic hemodynamic parameters (cardiac output, central venous pressure, and systemic vascular resistance) and hepatic and renal blood flow.
Head-up position and intraperitoneal pressure greater than 12 mm Hg should be avoided during laparoscopic surgery because they compromise hepatic and renal blood flow. Argon insufflation impairs liver blood flow. However, helium may be advantageous compared with CO2 insufflation.

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    • "Considering the fact that there was no significance in the recovery from an intense neuromuscular block between continuous infusion and single bolus administration of rocuronium [20], a possible explanation for the decrement in correlation coefficient between before and after PP is the effects of variable intra-abdominal pressure and position. A previous animal study reported that changes in the intra-peritoneal pressure and position significantly influence the hepatic blood flow [21]. They demonstrated that both, the portal and hepatic arterial blood flow were reduced in relation to an increased intra-abdominal pressure and head-up position rather than the systemic hemodynamic parameters [21]. "
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    ABSTRACT: Background This study investigated the effect of pneumoperitoneum on the recovery from intense neuromuscular blockade by rocuronium in healthy patients undergoing laparoscopic abdominal surgery. Methods Thirty adult patients undergoing laparoscopic abdominal surgery were studied. Anesthesia was induced with 1.5 mg/kg of propofol, 12 ug/kg of alfentanil and 0.6 mg/kg of rocuronium and maintained with 2 vol% of sevoflurane and 0.05-0.2 µg/kg/min remifentanil. The neuromuscular relaxation was monitored by Train-of-Four (TOF) and post-tetanic count (PTC). Additional rocuronium of 0.2 mg/kg was administered for deep neuromuscular blockade at 30 min after pneumoperitoneum. Before (PPpre) and 30 min after pneumoperitoneum (PPpost), PTC was measured at 6 min intervals. The relationship between PTC and the time interval to reappearance of T1 response was observed. Results The mean ± SD of the intervals between the detection of 4 counts of the PTC and the first response to TOF stimulation was 13.0 ± 1.1 min and 16.4 ± 6.3 min PPpre and PPpost, respectively (P = 0.20). There were significant negative relationships between PTC observed and the time interval to reappearance of T1 response (adjusted R2 = 0.869, P < 0.001 for PPpre data, and adjusted R2 = 0.561, P < 0.001 for PPpost data). Comparing the difference of regression equation between PPpre and PPpost data using a parallelism test, there was no statistically significant difference (P = 0.193). Conclusions This study showed that PP with intra-abdominal pressure at the level of 13-14 mmHg did not affect the recovery from intense neuromuscular blockade by rocuronium in healthy patients undergoing laparoscopic abdominal surgery.
    Korean journal of anesthesiology 07/2014; 67(1):20-5. DOI:10.4097/kjae.2014.67.1.20
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    • "Nevertheless, it is well hypothesized that pneumoperitoneum-induced renal dysfunction is a multifactorial phenomenon. For instance, the severity of the reduction in renal function following pneumoperitoneum is affected by the level of IAP [57], baseline volume status [59], degree of hypercarbia [62], positioning [57], and individual hemodynamic and renal reserve. Contradictory results have been reported in studies of cardiac output and release of vasopressin and endothelin in combination with pneumoperitoneum [63] [64] [65] [66], whereas compression of the urethra has now been ruled out as a factor contributing to the oliguria [52] [53] [60]. "
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    ABSTRACT: Elevated intra-abdominal pressure (IAP) occurs in many clinical settings, including sepsis, severe acute pancreatitis, acute decompensated heart failure, hepatorenal syndrome, resuscitation with large volume, mechanical ventilation with high intrathoracic pressure, major burns, and acidosis. Although increased IAP affects several vital organs, the kidney is very susceptible to the adverse effects of elevated IAP. Kidney dysfunction is among the earliest physiological consequences of increased IAP. In the last two decades, laparoscopic surgery is rapidly replacing the open approach in many areas of surgery. Although it is superior at many aspects, laparoscopic surgery involves elevation of IAP, due to abdominal insufflation with carbonic dioxide (pneumoperitoneum). The latter has been shown to cause several deleterious effects where the most recognized one is impairment of kidney function as expressed by oliguria and reduced glomerular filtration rate (GFR) and renal blood flow (RBF). Despite much research in this field, the systemic physiologic consequences of elevated IAP of various etiologies and the mechanisms underlying its adverse effects on kidney excretory function and renal hemodynamics are not fully understood. The current review summarizes the reported adverse renal effects of increased IAP in edematous clinical settings and during laparoscopic surgery. In addition, it provides new insights into potential mechanisms underlying this phenomenon and therapeutic approaches to encounter renal complications of elevated IAP.
    01/2014; 2014:1-15. DOI:10.1155/2014/731657
    • "The blood pressure is usually slightly increased because of carbon dioxide induced increased sympathetic tone and systemic vascular resistance.[23] Pneumoperitoneum reduces the splanchnic blood flow,[24] including renal flow as well. The reduced renal flow leads to reductions in urine output and creatinine clearance.[2526] "
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