La colecistectomia laparoscopica a “bassa pressione” nei pazienti ad alto rischio (ASA III e IV) nella nostra esperienza

The insufflation pressure used for laparoscopic cholecystectomy is usually 12-15 mm Hg, and a pneumoperitoneum with carbon dioxide has a significant effect on both cardiovascular and respiratory function. These effects are transient in young, healthy patients, but may be dangerous in ASA III and IV patients with a poor cardiac reserve. This study was designed to assess the feasibility of performing laparoscopic cholecystectomy at 6.5-8 mm Hg insufflation pressure in "high-risk" patients. Thirteen patients, 10 ASA III and 3 ASA IV, with cholelithiasis, were included in this study The insufflation pressure was 6.5-8 mm Hg, with a 10 degrees anti-Trendelenburg position. The cardiovascular and blood gas variables studied were: mean arterial blood pressure, heart rate, respiratory rate, and end-tidal CO2 pressure. The authors reported no conversions and no intra- or postoperative complications. During insufflation heart rate and mean arterial blood pressure increased minimally if compared with laparoscopic cholecystectomy at 12-15 mm Hg. Pa CO2 increased after insufflation (+5 mm Hg), and the end-tidal CO2 pressure gradient was moderate (3.5 mm Hg) and unchanged during surgery. A low-pressure pneumoperitoneum is feasible for laparoscopic cholecystectomy and minimizes the adverse haemodynamic effects of peritoneal insufflation

Haemodynamic variations and indices of cardiac performance assessed with PICCO system during bariatric laparoscopic surgery

monitoraggio emodinamico invasivo con sistema PiCCO in corso di chirugia bariatric

Transcranial doppler in 178 patients before, during, and after carotid endarterectomy

From July 1991 to March 1995, 178 patients who underwent 198 carotid surgical repairs were investigated preoperatively, intraoperatively, and postoperatively by transcranial Doppler sonography (TCD). Preoperative TCD evaluation showed stenosis of the middle cerebral artery (MCA) in 4 patients (2.2%), siphon stenosis in 3 (1.6%), incomplete circle of Willis in 23 (12.9%), a decrease of mean blood flow velocity more than 70% of the basal value during digital common carotid compression in 31 (17.9%), and a critical reduction of vasomotor reactivity (no significant increase of mean blood flow velocity in the MCA during breath-holding test) in 34 (19.1%). Nine patients (5%) had surgery without preoperative angiography. In those patients the indication for surgery was based on color Doppler imaging and TCD investigations. Ninety surgical procedures were carried out under general anesthesia and 108 under locoregional anesthesia. in 37 surgeries (31.7%) a shunt was inserted: The use of a shunt was based on a decrease of mean blood flow velocity in the MCA below 50% of the basal value under general anesthesia or loss of consciousness combined with a decrease of mean blood flow velocity in the MCA higher than 70% of the basal value when locoregional anesthesia was employed. Intraoperative TCD monitoring showed a decrease of mean blood flow velocity in the MCA due to shunt malfunction in (8.3%) of 36 surgeries, turbulence of blood flow during declamping in 79 procedures (39.8%), and microembolic events in 10 patients (5%) that were related to one transient and one permanent neurological deficit. Another permanent deficit occurred in a patient without TCD signs. After surgery, TCD reliably detected an early asymptomatic occlusion of the carotid artery, hyperperfusion syndrome in 12 (6.0%), and an increase of vasomotor reactivity in 10(29.4%) of 34 surgeries